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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604604
Report Date: 04/17/2025
Date Signed: 04/17/2025 04:19:02 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
07/28/2023 and conducted by Evaluator Juliana Barfield
COMPLAINT CONTROL NUMBER: 08-AS-20230728165332
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: 49DATE:
04/17/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director Cameron AzemikhahTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not give medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced subsequent complaint visit regarding the above-mentioned allegation. LPA was met by, identified herself to, and discussed the purpose of the visit with Director Cameron Azemikhah.

The Department's investigation consisted of record review and interviews with staff and outside sources. Resident (R1) was a total assist with medication and it was alleged that staff did not give medications as prescribed to (R1). Photographs from outside sources showed that there were two handwritten notes with the instructions to take “pills”. Review of facility email communications concluded that the event happened and a staff member was identified for placing medication with the notes in the resident room. Staff interviews revealed one job requirement for medication management is that staff are present with a resident during a medication pass.

(Cont'd on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
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 6
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
07/28/2023 and conducted by Evaluator Juliana Barfield
COMPLAINT CONTROL NUMBER: 08-AS-20230728165332

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: DATE:
04/17/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Executive Director Cameron AzemikhahTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident's room was not in good repair.
Facility staff did not safeguard resident's personal items.
Resident's room was not sanitary.
Staff did not provide adequate supervision.
Facility did not provide basic laundry service.
Resident call pendant was not in working condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced subsequent complaint visit regarding the above-mentioned allegation. LPA was met by, identified herself to, and discussed the purpose of the visit with Executive Director Cameron Azemikhah.

It was alleged (R1) room was not in good repair because the smoke alarm was chirping. Outside sources said they did not hear smoke alarms chirping in the facility at any time. Two residents stated that in the past they heard a chirping smoke alarm in their rooms. One resident asked maintenance to change the battery and it was changed the same day. The other resident stated that their alarm went off for two days. Staff interviews revealed the resident refused help from caregiving staff and waited for maintenance to change the battery on a Monday.

(Cont'd on page 1, 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20230728165332
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: 04/17/2025
NARRATIVE
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(Cont'd from 9099C, page 2)

(R1) did not subsequently contract for continued one hour checks in care plan or admission agreement. This allegation is unsubstantiated.

It was alleged the facility did not provide (R1) basic laundry service. (R1) contracted with facility to launder (R1) laundry once a week. Staff said that (R) had a history of mixing clean clothing with dirty clothing. Staff set the laundry hamper outside the room so clothing would not get mixed up. Staff were reminded by an outside party, on occasion, to do (R1) laundry and they laundered the clothing. Therefore, this allegation is unsubstantiated.

It was alleged that resident's call pendant was not working. Staff confirmed that resident call pendants were replaced immediately when staff became aware of the malfunction. Extra pendants are stored at the front desk. Staff interview and LPA observation indicated that staff have a call pager and walkie-talkie to respond to a resident call. Staff also have a master pendant to check on the operational status of the resident pendant before staff leave the resident unattended. Resident interviews confirmed that their pendants had never failed. Therefore, the allegation is unsubstantiated.

An exit interview was conducted with Cameron Azemikhah to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. His signature on this form acknowledges receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20230728165332
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: 04/17/2025
NARRATIVE
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(Cont'd from 9099A)

Cameron Azemikhah confirmed caregiving staff are trained to get a battery from the front desk to change a battery in a chirping smoke alarm. He said there are always batteries at the front desk. The local fire department reported that a smoke alarm is still working when it chirps and that the smoke alarm would alarm in the event of a fire. This allegation is unsubstantiated.

It was also alleged (R1) personal items were not safeguarded. (R1) listed items and signed an inventory list to indicate personal items brought into the facility. (R1) had possession of and controlled their personal items in their room. Cameron Azemikhah said facility is a cashless facility, meaning none of the services at the facility require cash. Cameron Azemikhah recommends nothing of real value be stored in resident rooms or the facility upon admission. Cameron Azemikhah conducts an internal investigation, contacts Community Care Licensing or the police as warranted, when a valuable item goes missing. According to residents and outside sources, lost linens and clothing were replaced or financially reimbursed. The allegation is therefore unsubstantiated.

It was alleged that (R1) room was not sanitary related to staff not cleaning a refrigerator and floors. (R1) residential agreement did not state who is responsible to clean (R1) refrigerator. The facility supplied (R1) the refrigerator and upon request, staff cleaned out refrigerator. Resident interviews, along with LPA observation of resident refrigerators, confirmed that refrigerators were clean. One outside source did not ask staff to clean the refrigerator but rather cleaned out old food items themselves.

Outside sources, residents, staff and LPA observations confirmed carpets and floors were clean and that spots on floors were cleaned by staff. Therefore, the allegation is unsubstantiated.

It was also alleged that facility did not provide adequate supervision for (R1). (R1) admission agreement and care plan indicated staff would do status checks on (R1) four (4) times per shift. There are three (3) shifts at facility for eight (8) hours each. The resident was independent in toileting and standby assistance when transferring. When resident experienced a series of falls, the facility increased supervision to one hour checks.

(Cont'd on 9099C page 2)
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20230728165332
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: 04/17/2025
NARRATIVE
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(Cont'd from 9099C)

The Department has investigated the above-mentioned allegation and has found that based upon record review and interviews, a preponderance of evidence exists to support the allegation. Therefore, this allegation is deemed substantiated.

A deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).
An exit interview was conducted with Cameron Azemikhah, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided during the visit. His signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20230728165332
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2025
Section Cited
CCR
87465(a)(4)
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A plan for incidental medical and dental care...to provide for assistance in obtaining such care, by compliance with the following:
The licensee shall assist residents with self-administered medications as needed.
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The licensee will conduct a one hour staff in-service with med techs
to review policies and procedures in regards to medication pass and Title 22 Requirements. An inservice sign in sheet, and course outline will be submitted to CCL by the POC date of 05/15/2025.
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 This requirement was not met as evidenced by: Based on interviews and a review of records, the licensee did not ensure staff assisted resident with administered medications as needed. This posed a potential health and safety risk to one (1) resident 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: Juliana Barfield
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6