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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604422
Report Date: 04/29/2025
Date Signed: 04/29/2025 12:59:46 PM

Substantiated


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
12/19/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20241219145135
FACILITY NAME:LA JOLLA CASA PACIFICAFACILITY NUMBER:
374604422
ADMINISTRATOR:FERNANDEZ, JENNIFERFACILITY TYPE:
740
ADDRESS:5468 PACIFICA DRTELEPHONE:
(858) 775-6935
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 5DATE:
04/29/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Lincesee Gus Fernandez and Staff Jennifer FernandezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not provide DNR form to emengency personnel
Staff did not destroy resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced follow up complaint investigation visit and delivered findings. The LPA introduced himself and disclosed the purpose of the visit to Staff Linda Gonzalez. Licensee Gus Fernandez arrived during the visit and assisted the LPA.
Throughout the investigation, the Department secured records and conducted interviews with external and internal sources.

It was alleged staff did not provide a Do-Not Resuscitate (DNR) form to emergency personnel. On December 19th, 2024, it was reported to the Department staff summoned emergency medical personnel for Resident # 1 (R1), but staff did not provide paramedics R1’s DNR form.

Interviews with internal and external sources confirmed R1 was on hospice and had a DNR form on file. During the incident in question, staff handed paramedics R1’s facility profile but did not hand paramedics R1’s DNR form. One source reported R1’s file had two DNR forms. (See LIC 9099-C for continuation of report.)
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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 5
Control Number 08-AS-20241219145135
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: LA JOLLA CASA PACIFICA
FACILITY NUMBER: 374604422
VISIT DATE: 04/29/2025
NARRATIVE
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One form was blank inside the binder and the completed DNR form was placed on the front sleeve of the binder. An interview with the licensee revealed that during the incident in question staff called the licensee and advised the fire chief wanted to speak with the licensee. The fire chief reported not being able to locate the DNR form. The licensee instructed the fire chief to look in the resident's file.

It was alleged staff did not destroy resident's medication. It was reported to the Department facility staff did not destroy R1 medication, but instead handed R1’s medication to R1’s family, after R1 was deceased. Interviews with internal sources reported staff released R1’s medication to R1’s family after R1’s hospice agency approved for the medication to be released. Additional interviews with internal sources revealed it was not the facility’s protocol to release medication to families, nor the hospice agencies. The facility’s protocol called for two staff to destroy the medication and sign the required destruction form. An interview with R1’s hospice service provider confirmed there was no indication the agency had approved the release of R1’s medication, and it was not common for this agency to retrieve, or destroy medication.

Based on evidence obtained, the allegations were substantiated and cited in an LIC 9099-D form. Plans of Corrections (POCs) were jointly formulated with Licensee Gus Fernandez.

An exit interview was conducted with Gus Fernandez, to whom a copy of this report, LIC 9099-D, LIC 811, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20241219145135
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: LA JOLLA CASA PACIFICA
FACILITY NUMBER: 374604422
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
04/29/2025
Section Cited
CCR
87469(c)(1)
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87469 Advanced Directives and Requests Regarding Resuscitative Measures (c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following:(1) Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel and identify the resident as the person to whom the order refers. This requirement was not met as evidenced by:
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Administrator agreed to provide training to all staff reagarding DNR forms, and provide the LPA an attendance sheet by 5/29/25.
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Based on interviews and review of records, the Licensee did not ensure R1's DNR form was provided to emergency medical personnel, which posed a potential health, safety, and personal rights risk to R1.
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Administrator nos keeps DNR forms above each residents bed.
Type B
04/29/2025
Section Cited
CCR
87465(i)
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87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requirement was not met as evidenced by:
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Administrator agreed to provide all staff training regarding medication destruction procedures and submit attendance sheet to LPA by 5/29/25.
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Based on interviews, the Licensee did not ensure R1's medicaiton was destroyed, which posed a pontential health, safety, and personal rights risk to residents 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.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
12/19/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20241219145135

FACILITY NAME:LA JOLLA CASA PACIFICAFACILITY NUMBER:
374604422
ADMINISTRATOR:FERNANDEZ, JENNIFERFACILITY TYPE:
740
ADDRESS:5468 PACIFICA DRTELEPHONE:
(858) 775-6935
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:6CENSUS: 5DATE:
04/29/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Lincesee Gus Fernandez and Staff Jennifer FernandezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
2
3
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9
Staff did not notify hospice of resident's death
Staff did not provide resident incontinence supplies
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced follow up complaint investigation visit and delivered complaint findings. The LPA introduced himself and disclosed the purpose of the visit to Staff Linda Gonzalez. Licensee Gus Fernandez arrived during the visit and assisted the LPA.

Throughout the investigation, the Department secured records and conducted interviews with external and internal sources.

It was alleged staff did not notify hospice of a resident's death. It was reported to the Department staff did not notify Resident # 1’s (R1) hospice provider of R1’s death. Interviews with internal and external sources revealed conflicting statements on if staff notified R1’s hospice agency. An internal source reported calling and leaving the hospice agency several messages informing the agency of R1 aspirating and eventual death.
(See LIC 9099-C for continuation of report.)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20241219145135
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: LA JOLLA CASA PACIFICA
FACILITY NUMBER: 374604422
VISIT DATE: 04/29/2025
NARRATIVE
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 The hospice agency reported having a notification on file that the facility reported the death at approximately 9:30 AM on the day of the incident, but no previous notes noting aspiration, nor R1’s impending death. Although hospice did not have any previous notes indicating staff had called the agency, it is unclear if the messages were not received, or if staff did not contact the agency. The LPA made several attempts to contact a pertinent sources to confirm if staff notified the agency, but these attempts were unsuccessful.

It was alleged staff did not provide R1 incontinence supplies. It was reported to the Department R1 resided at the facility for two days and required incontinence pads. The facility allegedly did not have any supplies available. Interviews with internal sources revealed it was the resident’s, hospice providers, or resident’s responsible party to provide incontinence supplies. One interview revealed it had occurred staff had to barrow supplies from other resident to assist an other resident. Although one source reported the facility may run low on incontinence supplies, it was reported staff always provided incontinence supplies to residents. The LPA toured the facility on multiple occasions an observed extra incontinence supplies, including briefs, wipes and pads.

Based on the evidence obtained, the allegations were unsubstantiated.

An exit interview was conducted with Licensee Gus Fernandez, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5