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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604604
Report Date: 03/13/2025
Date Signed: 03/13/2025 03:09:48 PM

Unsubstantiated


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
09/04/2024 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20240904154400
FACILITY NAME:PACIFICA SENIOR LIVING POWAYFACILITY NUMBER:
374604604
ADMINISTRATOR:AZEMIKHAH, CAMERONFACILITY TYPE:
740
ADDRESS:12750 GATEWAY PARK ROADTELEPHONE:
(858) 451-9933
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:72CENSUS: 46DATE:
03/13/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director (ED) Cameron AzemikhahTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility did not ensure that residents had running water.
Facility did not meet resident's hygiene needs.
Facility did not follow reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced visit to deliver investigative findings on the above complaint allegations. LPA Correia met with Executive Director (ED) Azemikhah to whom was explained the purpose for the visit.

The Department’s investigation included interviews with staff, residents, and outside sources, as well as facility records reviews.

It was alleged the facility did not ensure that residents had running water and did not ensure residents hygiene needs were met. An interview with the Executive Director (ED) revealed the facility had a planned water outage scheduled for September 4, 2024, due to an upgrade in their water system. The interview also revealed several measures were put in place to ensure the residents care needs were met, including dedicated empty rooms with full water use, and offering showers a day before or after for residents whose care plan included showers during the day of the outage. Staff and resident interviews also confirmed water stations were placed throughout the facility during the day of the outage.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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 2
Control Number 08-AS-20240904154400
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 LIVING POWAY
FACILITY NUMBER: 374604604
VISIT DATE: 03/13/2025
NARRATIVE
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It was also alleged the facility did not follow reporting requirements. Interviews conducted with staff, residents, and outside sources, as well as facility records reviews revealed the residents and/or their Responsible Parties (RPs) were notified of the date and times of the outage, and postings of the date and times were displayed throughout the facility. A facility records review and an interview with an Outside Source Agency confirmed the dates and times of the outage and receipt of notifications.

Based on the interviews and records reviews the above listed allegations were determined to be Unsubstantiated, as the preponderance of evidence standard was not met. An exit interview was conducted with ED Azemikha who was informed that a copy of the reports will be provided at the conclusion of the visit. Signature below confirms receipt of the reports.
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2