374604300-6-16-2023-08-AS-DNGN-CSV29Q-20230616171220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604300
Report Date: 06/16/2023
Date Signed: 06/16/2023 05:12:30 PM

Document Has Been Signed on 06/16/2023 05:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	PACIFICA SENIOR LIVING OCEANSIDE		FACILITY NUMBER:	374604300
ADMINISTRATOR:	BANKS, JAQUELINE		FACILITY TYPE:	740
ADDRESS:	5508 AVENIDA PACIFICA WAY		TELEPHONE:	(760) 978-6602
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	165	CENSUS: 108	DATE:	06/16/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Executive Director Jackie Banks		TIME COMPLETED:	05:20 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Jackie Banks.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (transmission date 05/19/2023). According to the LIC624, errors by med tech Staff #1 (S1) led to Resident #1 (R1) receiving one (1) extra dose per day of one (1) of their medications, beyond what was prescribed by their physician, during the period of 05/01/2023 through 05/12/2023. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. The medication errors resulted in increased sleepiness and decreased appetite for R1 during the above dates, but they did not result in serious injury/illness to R1 or require hospitalization or medical treatment.

During today’s visit, LPA performed a brief facility tour and welfare check on R1. R1 was active, alert, animated, and verbally stated they felt well. LPA also reviewed pertinent records and interviewed relevant staff.

Due to their baseline memory loss, R1 was not able to participate as a reliable historian/interviewee. LPA observed R1 resided in the facility’s secured memory care neighborhood. Per their LIC602 Physician’s Report, R1 was diagnosed with Dementia and required staff assistance with taking their prescribed medications.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374604300
	VISIT DATE: 06/16/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 809]

Staff interviews, corroborated by medication and employee records, revealed: The twelve (12) medication errors were first recognized/identified by Licensee on 05/13/2023. Upon discovery, Licensee timely phoned R1’s physician and responsible person and provided increased observation to R1 over the next 72 hours. Licensee immediately removed S1 from medication pass duties with the intention of retraining them before reinstating them. However, interviews and records showed S1 soon after resigned their employment. During the period of approximately 05/01/2023 through 05/12/2023, R1 tended to sleep more and eat less than their usual baseline level. After correcting and returning to the prescribed dosing, R1 went back to baseline sleeping and appetite, with no long-term health consequences.

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D) for the medication errors. A Plan of Correction was jointly developed with the licensee. LPA also identified one Technical Violation regarding Reporting Requirements, and provided education, accordingly.

An exit interview was conducted with Banks, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 06/16/2023 05:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374604300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/15/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:	1 2 3 4 5 6 7	Records and interviews show: a) S1 left facility employment and their last day worked 05/17/2023; and, b) Licensee retrained its remaining med tech team on accurate medication pass procedures on 06/01/2023. These actions resolve the deficiency.
	8 9 10 11 12 13 14	Based on records and interviews, the licensee's staff (S1) did not assist 1 of 108 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3