374604300-9-16-2024-08-AS-JLOT-D9JKAM-20240928074408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604300
Report Date: 09/16/2024
Date Signed: 09/16/2024 11:07:26 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
03/14/2024 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20240314090813

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: 74	DATE:	09/16/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Business Office Manager Virgina Rodriguez		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Questionable death
Staff did not administer medications as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Rebecca Ruiz and Hannah Rodgers conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above mentioned allegations. LPAs were greeted by, identified themselves to, and explained the purpose of the visit and the basic elements of the complaint with Business Office Manager Virgina Rodriguez.

During today’s visit, LPAs reviewed and obtained copies of facility records.

The Department’s investigation consisted of interviews with staff and outside sources, records review, and a tour of the facility. It was alleged that Resident 1’s (R1’s) death was questionable and that staff did not administer medications as prescribed.

Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

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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Control Number 08-AS-20240314090813

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374604300
	VISIT DATE: 09/16/2024

NARRATIVE

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Review of R1’s physician report dated January 2024 and pre-appraisal assessment records dated 1/27/2024 revealed that R1 did not have any memory impairment, had a diagnosis of heart disease, was confused, but able to follow directions and communicate needs, was not able to administer or store own medications and was not receiving hospice services. Review of facility progress notes for R1 revealed that in early February 2024, R1 was observed by facility staff to have a change in condition and was experiencing increasing confusion. R1 was transported to the hospital where R1 received medication and treatment for a urinary tract infection. On 2/21/2024, R1 expressed feeling drowsy to facility staff and staff notified R1’s spouse. R1’s spouse spoke to R1’s primary physician who requested that R1 be sent to the hospital. Facility staff called 911 and R1 was assessed to be lethargic and non-responsive by paramedics. Paramedics administered a Narcan injection and transported R1 to the hospital, where R1 was admitted and treated for a urinary tract infection. At the hospital, R1 tested positive for narcotics during urine analysis testing. R1 was discharged back to the facility on 2/23/2024 and was readmitted to the hospital on 2/24/2024 after displaying stroke-like symptoms. R1 was moved out of the facility on 2/27/2024 and review of R1’s death certificate revealed that R1 passed away on 3/5/2024 with the cause of death listed as cerebral atherosclerosis and unspecified heart failure. Additionally, R1’s death certificate did not list the presence of narcotics in R1’s urine, the Narcan administration on 2/21/2024, or any other conditions as having contributed to R1’s death.

Review of R1’s medication record dated 2/29/2024 and interviews with facility staff revealed that R1 was not prescribed any narcotic medications and staff denied administering narcotic medications to R1. Interviews with facility staff revealed that all narcotic medications are stored in a locked cabinet in the medication room and are counted at the beginning of each shift by medication technicians. Interviews with staff and R1’s progress notes stated that R1’s spouse notified facility staff on 2/21/2024 that R1 had tested positive for narcotics and the Resident Care Director and medication technicians on shift conducted an additional narcotic medication count that day and did not discover any inconsistencies. Review of narcotic count records for February 2024 did not reveal any inconsistencies with narcotic medication counts for residents at the facility.

Continued on LIC9099-C page...

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240314090813

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374604300
	VISIT DATE: 09/16/2024

NARRATIVE

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Interviews with an outside medical professional revealed that the administration of Narcan could cause a false positive on a drug screening. Additionally, the outside medical professional stated that the administration of Narcan and the potentially false positive narcotic result were not a direct cause of death for R1. Interviews with staff and outside sources and review of records did not reveal how R1 could have taken the narcotics.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Business Office Manager Virginia Rodriguez, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) 346-3976
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024

LIC9099 (FAS) - (06/04)

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