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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604177
Report Date: 09/21/2023
Date Signed: 09/21/2023 09:00:34 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/23/2022 and conducted by Evaluator Renita Hall
COMPLAINT CONTROL NUMBER: 08-AS-20220923115903
FACILITY NAME:PACIFICA SENIOR LIVING BONITAFACILITY NUMBER:
374604177
ADMINISTRATOR:LEON II, RENEFACILITY TYPE:
740
ADDRESS:3434 BONITA ROADTELEPHONE:
(619) 476-9444
CITY:CHULA VISTASTATE: CAZIP CODE:
91910
CAPACITY:0CENSUS: DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:TIME COMPLETED:
08:57 AM
ALLEGATION(S):
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Facility does not have an administrator.
Food served to residents was not protected against contamination.
INVESTIGATION FINDINGS:
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On September 30, 2022 LPA observed Rene Leon the Administrator had arrived to participate in the investigation with April Cervantes the Activities Director.

LPA observed kitchen facility no discrepancies found and food handling practices were in place. Kitchen staff were able to explain how to properly handle food without cross contamination. No incidents were reported to established a break out of food contamination/poisoning amongst residents by the facility and no other residents reported any illness due to the food.

There was insufficient evidence found to support the allegations that Food served to residents was not protected against contamination and Facility does not have an administrator. Due to a lack of evidence, the allegations are deemed to be unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. A copy of this report and Licensee's Rights (LIC 9058 03/22) were mailed to the last known address for the facility.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Renita HallTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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