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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604539
Report Date: 09/14/2023
Date Signed: 09/14/2023 12:02:30 PM


Document Has Been Signed on 09/14/2023 12:02 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 ENCINITASFACILITY NUMBER:
374604539
ADMINISTRATOR:WATKINS, MELISSAFACILITY TYPE:
740
ADDRESS:504 S EL CAMINO REALTELEPHONE:
(760) 452-0615
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:90CENSUS: 56DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Executive Director Melissa Watkins and Resident Services Director Justine HernandezTIME COMPLETED:
12:10 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 Executive Director Melissa Watkins and Resident Services Director Justine Hernandez.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 06/29/2023. According to the LIC624: on 06/28/2023, an error by Staff #1 (S1) led to Resident #1 (R1) receiving one of their prescribed eye drops at the incorrect time. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. The medication error did not result in any adverse health consequence for R1.

During today’s visit, LPA performed a brief facility tour and welfare check on residents in care. LPA also interviewed relevant staff and reviewed pertinent care records and written correspondence.

Per their latest LIC602 Physician’s Report (dated 06/03/2022): R1 was able to manage their own medications. However, staff interviews revealed that in practice, R1 required staff assistance with storing and taking their prescribed medications, and that Licensee was indeed providing this service to R1.

Staff interviews, corroborated by date and time-stamped records, showed: During the PM shift on 06/28/2023, S1 gave R1 their AM-prescribed eye drops, instead of their PM-prescribed eye drops. This meant that R1 received a net double/extra dose of their AM-prescribed eye drops that day. The overdose did not result in any adverse symptom for R1. The medication error was timely reported to R1’s primary care physician (PCP) and R1’s responsible person. The PCP advised that no medical intervention was necessary for R1. Licensee's staff provide increased observation of R1 over the next 48 hours, which were uneventful.

[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: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
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 ENCINITAS
FACILITY NUMBER: 374604539
VISIT DATE: 09/14/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

Per staff interviews, the day after the incident, Licensee timely retrained S1 on accurate medication pass procedures, to include skills validation. Per training records, on 07/24/2023, Licensee also retrained its larger medication technician team on accurate medication pass procedures.

A preponderance of evidence exists to show that during the incident in question, Licensee’s staff (S1) did not give medication to R1 as it was prescribed. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). LPA also issued a Technical Violation (TV) regarding Reporting Requirements, and Technical Assistance (TA) regarding Medical Assessments.

An exit interview was conducted with Watkins, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC9102-TA, 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: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/14/2023 12:02 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 ENCINITAS
FACILITY NUMBER: 374604539

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2023
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:
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Per records and interviews, following the incident, Licensee retrained S1 (on 06/29/2023) and its larger medication technical team (on 07/24/2023) on accurate medication pass procedures. These actions satisfy the Plan of Correction.
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Based on records and interviews, the licensee did not assist 1 of 56 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health 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: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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