374604300-11-29-2022-08-AS-IESA-CLP6FX-20221130194704

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604300
Report Date: 11/28/2022
Date Signed: 11/29/2022 09:26:58 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
09/27/2021 and conducted by Evaluator Daniel Pena

COMPLAINT CONTROL NUMBER: 08-AS-20210927093155

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: 113	DATE:	11/28/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jenifer Gephart, Resident Services Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Lack of supervision resulted in serious injury to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Pena completed an investigation regarding the aforementioned complaint allegation and on 11/28/2022, visited the facility to deliver findings. LPA introduced himself to reception staff. After displaying his identification and explaining the purpose for the visit LPA was allowed into the facility. LPA was met by Jenifer Gephart, Resident Services Director, to whom the elements of this complaint were discussed.

This complaint alleges that lack of supervision resulted in the serious injury of a resident (Resident 1-R1) in care. On 9/27/2021, the San Diego Adult and Senior Care Program Office received a complaint regarding the aforementioned allegation. The Department’s investigation consisted of facility visits, resident and outside source record reviews, and interviews with staff and R1’s responsible person.

R1 moved into the community on 10/25/2019. According to R1’s Physician’s Report, R1 was on hospice with a terminal diagnosis, had dementia, acute kidney failure, Diabetes Type II, hyperlipidemia and

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

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-20210927093155

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374604300
	VISIT DATE: 11/28/2022

NARRATIVE

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orthostatic hypotension. R1 suffered from confusion and forgetfulness and was unable to communicate their needs. R1 required assistance with activities of daily living such as dressing, bathing, toileting, taking prescribed medications and managing their own cash resources. R1 was non-ambulatory based on their physical and mental condition. Interviews and record reviews reflect that R1 used a walker but required standby assistance when ambulating.

Records also showed that R1 was a documented fall risk, experiencing falls at the facility. R1’s 9/28/2020, assessment for Ambulation and Transfers, indicated that R1 required one (1) person total assist or wheelchair escort to and from activities, meals, etc. R1’s Needs and Services Plan, dated 9/28/2020, showed that R1 required standby assistance by facility staff to prevent falls. It should also be noted that staff was required to provide R1 assistance with transfers.

Investigation revealed that on 09/26/2021, at about 4:00 PM, R1 was in the common area of the memory care unit with about 10-12 other residents. Staff 1 (S1) was in the common area, Staff (S2) and Staff (S3) were preparing medications in the medication room and Staff 4 (S4) was preparing the dinner meal in the kitchen.

At about this time, S2 and S3 responded to knocking on the memory care unit front doors. Two visitors informed S2 and S3 that a person had fallen outside. It was later learned that the person was a visitor who had come to visit Resident 2 (R2). S2 and S3 responded to the scene and tended to the visitor and called 911 for emergency medical response.

While S2 and S3 were assisting the visitor, S1 arrived at the scene to assist. S1 had left the memory care residents unsupervised. Interviews revealed that S1 had no business coming to the scene outside and was told to return to the memory care unit to supervise the residents. Interviews reported, at this time, S4 went to R2’s room to check their status. S4 found R1 on the floor, lying next to their walker. R1 was bleeding from a facial injury. It was apparent R1 had fallen in R2’s room but the incident was not witnessed.

Interviews stated that a few minutes later, S1 went back to the scene outside and informed staff that R1 was found in R2’s room and had a facial injury. S1 again was directed to return to the memory care unit and assist R1. S1 told S3 to come and help R1 and S1 would stay outside with S2 until the paramedics arrived. S3 went to R2’s room and administered first aid to R1 until paramedics arrived. Paramedics arrived,

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20210927093155

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374604300
	VISIT DATE: 11/28/2022

NARRATIVE

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stabilized R1 and the visitor and transported them to a local hospital. Records illustrate that R1 was later diagnosed with a nasal bone fracture.

According to interviews, upon finding R1 on the floor, S4 called for S1 and requested they evaluate R1 and provide first aid. S1 told S4 that they (S1) were not scheduled to perform the duties of a Med Tech but that of caregiver. S1 told S4 that S3 was the scheduled Med Tech and S1 would go get S3 to assist R1. Interviews with S1 confirmed that they admittedly did not render first aid to R1 because they were not the scheduled Med Tech. It should be noted that S1 was a trained Med Tech and should have assisted R1, regardless of their shift assignment for the day. During the investigation, S1 said they were submitting their letter of resignation.

The amount of time which passed before staff located R1 and began first aid could not be determined. Facts show that, the circumstances of the event involving the visitor, drew S1’s attention from their primary responsibility to provide supervision to the residents in the memory care unit. Investigation revealed S1 abandoned their post leaving R1 unsupervised which resulted in a serious injury.

The Department has investigated the allegation that lack of supervision resulted in the serious injury of a resident in care. Based on interviews and records reviewed, sufficient evidence was obtained to support the allegation. The preponderance of evidence standard has been met. Therefore, the findings are determined to be Substantiated.

A deficiency is cited in accordance to the California Code of Regulations, Title 22, Division 6, Chapter 8, and is noted on the attached LIC9099-D. An immediate civil penalty of $500 was assessed for the facility’s lack of supervision resulting in a serious injury to a resident in care. At this time, per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.

Director Gephart was provided a copy of the Licensee’s appeal rights (LIC9058 01/16) and their signature on this form, acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided to Director Gephart.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20210927093155

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE	FACILITY NUMBER: 374604300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/29/2022 Section Cited CCR 87464	1 2 3 4 5 6 7	87464 Basic Services (f)(1) Basic services shall at minimum include: (1) Care and supervision as defined in Section 87101 (c)(3) and Health and Safety Code section 1569.2 (c) This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee has agreed to procure vendorized care and supervision training within 24 hours and ensure 100 percent of care staff participate. Licensee will submit a sign-in sheet to LPA by December 29, 2022.
	8 9 10 11 12 13 14	Based on interviews and record reviews, the licensee did not provide supervision as defined in Section 87101 (c)(3) for 1 of 104 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: Simon Jacob	TELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel Pena	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

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