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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604604
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:58:48 PM

Unfounded


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
03/17/2025 and conducted by Evaluator David Roman
COMPLAINT CONTROL NUMBER: 08-AS-20250317160123
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:
03/20/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director, Cameron AzemikhahTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Questionable Death.
Staff did not notify residents authorized representative of incident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), David Roman, conducted an unannounced complaint investigation visit. LPA D. Roman identified himself and disclosed the purpose of the visit to Executive Director, Cameron Azemikhah.

On March 17, 2025, it was reported to the Department that there was a questionable death, and staff did not notify resident's authorized representative of the incident.

During today's visit, LPA D. Roman reviewed records and interviewed staff which revealed the resident in question did not reside in the Assisted Living portion of the facility. This resident did reside in the 55+ Independent Living facility in a different address, adjacent and associated to the Pacifica Senior Living Poway. The Independent Living component is not licensed through California Department of Social Services, Community Care Licensing Division. Based on the information revealed during the visit, these allegations are deemed to be unfounded. An unfounded determination means that the allegation was false, could not have happened and/or is without a reasonable basis. (Cont. 9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: David Roman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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 2
Control Number 08-AS-20250317160123
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: 03/20/2025
NARRATIVE
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An exit interview was conducted with Executive Director, Cameron Azemikhah, to whom a copy of this report, and licensee/Appeal Rights were provided. Their signature acknowledges a receipt of this report and their rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: David Roman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2