374604300-6-17-2021-08-AS-SJAB-C89RMJ-20211029130847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604300
Report Date: 06/17/2021
Date Signed: 06/17/2021 10:08:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/10/2021 and conducted by Evaluator Kristina Ryan

COMPLAINT CONTROL NUMBER: 08-AS-20210610132241

FACILITY NAME:	PACIFICA SENIOR LIVING OCEANSIDE		FACILITY NUMBER:	374604300
ADMINISTRATOR:	EADS. JONETTA		FACILITY TYPE:	740
ADDRESS:	5508 AVENIDA PACIFICA WAY		TELEPHONE:	(760) 978-6602
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY:	165	CENSUS: 112	DATE:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Executive Director, Jackie Banks		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to administer medications as prescribed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Kristina Ryan and Licensing Program Manager (LPM) Simon Jacob conducted an unannounced complaint visit to initiate an investigation regarding the above-mentioned allegation. LPA and LPM were met and granted entry by Executive Director Jackie Banks and explained the reason for the visit.

On June 10, 2021, it was alleged that facility staff did not administer medication to Resident 1 (R1) ( see LIC 811 Confidential Names List) as prescribed. Interviews conducted with Administrator, caregivers, responsible parties and records review revealed that staff failed to administer medications as prescribed.

On June 8, 2021 the facility had self-reported that (R1) was given the wrong medications on June 6, 2021. Facility administered five medications incorrectly to R1. R1 was taken to urgent care by their responsible party. Exams and testing at Urgent Care revealed that R1 did not suffer health ramifications from the error.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 08-AS-20210610132241

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/17/2021

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

The Department has found there is a preponderance of evidence to prove the alleged violation occurred and is therefore determined to be substantiated. Deficiency is cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D.

An exit interview was conducted, and a copy of this report, Licensee Appeal Rights (LIC 9058 01/16), and LIC 811 Confidential Names List, were provided to Administrator, Jackie Banks via electronic mail. An electronic read receipt verifies receipt of these documents.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20210610132241

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/17/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87455 Incidental Medical and Dental Care (c)(2)... the facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:...Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by;	1 2 3 4 5 6 7	Executive Director will provide training to all Med-Tech staff regarding administration of medication. Training will be provided by July 9, 2021. Training topics discussed and sign in sheet will be provided to LPA by July 12, 2021.
	8 9 10 11 12 13 14	Based on interviews and records review, the facility staff did not administer medications as prescribed for 1 out of 112 residents,which poses a potential health risk to residents 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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Kristina Ryan	TELEPHONE: (619) 929-1438
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3