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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604542
Report Date: 10/30/2023
Date Signed: 10/30/2023 03:10:51 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
10/05/2023 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20231005093615
FACILITY NAME:PACIFICA SENIOR RANCHO PENASQUITOSFACILITY NUMBER:
374604542
ADMINISTRATOR:MCDONALD, JILLFACILITY TYPE:
740
ADDRESS:12979 RANCHO PENASQUITOS BLVDTELEPHONE:
(858) 215-5820
CITY:SAN DIEGOSTATE: CAZIP CODE:
92129
CAPACITY:120CENSUS: DATE:
10/30/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Executive Director Austin IrwinTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff did not treat resident with dignity
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Austin Irwin.

Throughout the investigation, the Department secured pertinent records and conducted interviews.
It was alleged staff did not treat a resident with dignity. It was reported to the Department someone witnessed a staff member place their hand over a Resident # 1’s (R1) mouth and tell R1 to be quiet. Review of records along with an interview confirmed Staff # 1 (S1) had admitted the incident had occurred. Although, S1 may not have meant any harm to R1, an internal investigation revealed S1 violated company policy. Based on evidence obtained, the allegation was Substantiated, and cited in LIC 9099D.

Review of additional records revealed in-service training was conducted for all staff at the facility, after the incident occurred. (See LIC 9099C for continuation of report.)
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
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-20231005093615
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 RANCHO PENASQUITOS
FACILITY NUMBER: 374604542
VISIT DATE: 10/30/2023
NARRATIVE
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An exit interview was conducted with Irwin, to whom a copy of this report, LIC 9099D, Licensee/Appeals Rights (LIC 9058), and clear Plan of Correction Letter, were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20231005093615
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 RANCHO PENASQUITOS
FACILITY NUMBER: 374604542
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Executive Director provided the LPA proof of in- service training provided to all staff, regarding elder abuse. POC was cleared on today's date.
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Based on review of records and an interview, the Licensee did not ensure S1 accorded R1 with dignity in their relationship, which posed a potential health, safety and personal rights risks 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3