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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604300
Report Date: 12/08/2023
Date Signed: 12/08/2023 05:13:47 PM


Document Has Been Signed on 12/08/2023 05:13 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 OCEANSIDEFACILITY NUMBER:
374604300
ADMINISTRATOR:BANKS, JAQUELINEFACILITY TYPE:
740
ADDRESS:5508 AVENIDA PACIFICA WAYTELEPHONE:
(760) 978-6602
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:165CENSUS: 112DATE:
12/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Sales Director Jiovanni Anderson-Diaz and Business Office Manager Fina TuiseeTIME COMPLETED:
05:20 PM
NARRATIVE
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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 Sales Director Jiovanni Anderson-Diaz and Business Office Manager Fina Tuisee. LPA also spoke via phone with Executive Director Jackie Banks during the visit.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/15/2023), involving Resident #1 (R1) and Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying they were safe. LPA reviewed and collected copies of pertinent care and administrative/personnel records. LPA also interviewed R1 and relevant staff.

According to R1’s latest LIC602 Physician’s Report (dated 01/18/2022): R1 was diagnosed with Dementia and relied on staff for help with personal care tasks, to include dressing and incontinence care. R1’s physician wrote that while R1 was confused/disoriented, they were still able to communicate their needs.

During interview of R1, LPA observed: R1 could not recall the incident due to their baseline memory loss. However, R1 demonstrated the ability to converse. R1 made good eye contact, used appropriate social graces, quickly understood what was said to them, and quickly constructed full, coherent sentences in their replies to LPA.


[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 12/08/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

According to records and staff interviews: Sometime around September 2023, S1 used their cell phone to film a video of themselves, S2 and S3, while the three staff were with R1 inside R1’s bedroom. The video, which was around four to five minutes long, depicted S2 providing incontinence care to R1. R1 was seen in the video to lay in bed bottomless (i.e., without pants or depends on). While S2 performed care on R1, S3 said multiple profanities, including a racial slur, towards S2. While these comments were not directed at R1 per se, R1 was in immediate ear shot and the racial slur S2 used coincided with R1’s actual race/ethnicity.

On 11/11/2023, facility management received constructive knowledge regarding the existence of an inappropriate video, and obtained the footage the same day. S1, S2, and S3 were immediately suspended pending internal investigation. The incident was timely reported to CCLD, the San Diego Long-Term Care Ombudsman, and local police. While S3 denied knowledge of the video, S1 did acknowledge the video’s existence. S2 also acknowledged its existence, and further confirmed that the video accurately depicted what the three staff did in the room on the date in question. Personnel records showed: Licensee terminated the employment of S1, S2, and S3 based on the investigation findings, and on 11/12/2023 retrained its remaining staff on topics related to Resident’s Personal Rights.

A preponderance of evidence exists to show that during the above incident, the actions and/or inaction of licensee’s staff undermined R1’s personal rights to both dignity and privacy. Also, per records review, and corroborated by manager interview: Licensee did not possess an updated LIC602 Physician’s Report (or equivalent medical assessment) completed within the last twelve (12) months for R1, which is a requirement for any resident diagnosed with Dementia.

Three (3) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee.

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

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/08/2023 05:13 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: 12/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2023
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff...” This requirement was not met, as evidenced by:
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Manger interviews, corroborated by personnel records, showed: Licensee suspended S1, S2, and S3 on 11/11/2023, then administratively terminated their respective employments on 11/20/2023. On 11/12/2023, Licensee retrained its remaining staff on topics related to Resident’s Personal Rights. These actions resolve the deficiency.
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Based on records and interviews, during the incident, licensee’s staff (S1, S2, and S3) did not accord 1 of 112 residents (R1) dignity, which posed an immediate personal rights risk to persons in care.
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Type A
12/09/2023
Section Cited
CCR87468.2(a)(1)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in…personal care and assistance…”
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Manger interviews, corroborated by personnel records, showed: Licensee suspended S1, S2, and S3 on 11/11/2023, then administratively terminated their respective employments on 11/20/2023. On 11/12/2023, Licensee retrained its remaining staff on topics related to Resident’s Personal Rights. These actions resolve the deficiency.
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This requirement was not met, as evidenced by: Based on records and interviews, during the incident, licensee’s staff (S1, S2, and S3) did not uphold the personal privacy of 1 of 112 residents (R1), which posed an immediate personal rights risk to persons in care.
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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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/08/2023 05:13 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: 12/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2024
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia: “(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.”
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Licensee agreed to coordinate with R1’s responsible person and physician, as needed, to obtain an updated LIC602 Physician’s Report for R1. Licensee agreed to E-mail a copy of R1’s updated LIC602 to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, licensee did not ensure that 1 of 112 residents (R1), who was diagnosed with dementia, had a medical assessment performed within the last year, which posed a potential health, safety, and personal rights risk to persons in care.
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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 TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4