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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 02/24/2025
Date Signed: 02/24/2025 11:22:10 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241210160828
FACILITY NAME:PACIFICA SENIOR LIVING MISSION VILLAFACILITY NUMBER:
415601046
ADMINISTRATOR:SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:60CENSUS: 51DATE:
02/24/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Shayan GheisarTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Licensee did not issue a timely refund of advance fees as required.
INVESTIGATION FINDINGS:
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On February 24, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Shayan Gheisar and explained the purpose of the visit.

Regarding the allegation, Licensee did not issue a timely refund of advance fees as required, according to the reporting party, although all of Resident 1’s (R1’s) belongings were removed from the facility on 11/02/2024, the family still has not received a refund due of $2,094 for the full month fees paid up-front.

During the investigation, LPA collected information and reviewed documents. Based on the admission agreement reviewed, it indicated “Within fifteen (15) days after your personal property is removed from your apartment, your estate, or other person or entity responsible for payment of fees under this Agreement, will receive a refund of any fees paid in advance covering the period after your personal property has been removed.” LPA observed a copy of the refund check that was provided to R1’s responsible party, however it was not issued until 12/17/24, which was passed the 15 days.

Based on information collected, records reviewed, interviews conducted and observations, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties. Report is reviewed with Administrator and a copy is provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241210160828

FACILITY NAME:PACIFICA SENIOR LIVING MISSION VILLAFACILITY NUMBER:
415601046
ADMINISTRATOR:SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:60CENSUS: DATE:
02/24/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Shayan GheisarTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff neglect resulted in resident’s death.
Staff did not dispense medication to resident as prescribed.
Licensee did not ensure resident’s bathroom was in good repair.
Staff did not ensure resident was provided adequate bed linens.
Staff did not ensure resident was provided adequate postural supports.
INVESTIGATION FINDINGS:
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On February 24, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Shayan Gheisar and explained the purpose of the visit.

Regarding the allegation, staff neglect resulted in resident’s death, the reporting party indicated, Resident 1 (R1) was a resident from October 2024 till November 2024 and was able to walk, talk, eat on his/her own, however when he/she left the facility, R1 lost weight and could not do anything without assistance. R1 passed away at the hospital 11/19/2024.

During the investigation, the Department reviewed copies of R1’s file. R1 was admitted to the facility on 10/17/24 and was a resident at the community for only two weeks. LPA reviewed R1's care notes, service plan, level of care and the Department did not find any indication of neglect or lack of care and supervision. There was no indication the facility neglected the resident based on records reviewed. R1 died after leaving the facility. (Continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
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 5
Control Number 14-AS-20241210160828
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046
VISIT DATE: 02/24/2025
NARRATIVE
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Regarding the allegation, staff did not dispense medication to a resident as prescribed, according to the reporting party, when R1 arrived at the facility on 10/17/24, staff did not dispense R1’s evening medications or morning medications the next day.

During the investigation, LPA reviewed documents provided by the facility and interviewed the administrator. The administrator denied the allegation and indicated that R1’s family did not provide medications to the facility when R1 moved in and the facility had to order the medications through the pharmacy, however the pharmacy was unable to deliver all the medications timely. Based on the QMAR reviewed, the facility noted that some of the medications were not available at the facility, however the ones that the pharmacy delivered were provided to R1. In addition, based on R1's care notes, it was noted that the facility called the pharmacy on 10/17/24 to re-order all of R1's medications, however the pharmacy was only able to deliver some of the R1's medications on 10/18/24 in the morning.

Regarding the allegation, Licensee did not ensure resident’s bathroom was in good repair, according to the reporting party, R1’s toilet tank was missing completely.

During the investigation, LPA observed the toilet tank in good repair and fixed in the room R1 used to stay in. LPA reviewed a receipt from the administrator that indicated, on 10/24/24 a new toilet was purchased and replaced on the same day. LPA confirmed with the Maintenance Director that the toilet was fixed the same day it was bought.

Regarding the allegation, staff did not ensure resident was provided with adequate bed linens, according to the reporting party, R1’s family provided sheets to R1 but during a visit on 10/26/24, it was observed that R1 did not have any linens and staff indicated that the linens were being washed.

During the investigation, LPA interviewed administrator and staff and observed 5 resident rooms. LPA observed all rooms to have bed linens. Based on interviews with housekeeping staff, it was indicated that bed linens are provided by family and staff wash them once a week or as needed.

Regarding the allegation, staff did not ensure resident was provided postural supports, according to the reporting party, R1 was noted to be a fall risk, however the facility did not provide any equipment to prevents falls such as grip bars or slip-resistant mats. (Continue to 9099C)
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20241210160828
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046
VISIT DATE: 02/24/2025
NARRATIVE
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During the investigation, LPA reviewed R1's file and interviewed the administrator. Based on R1's physician's report, R1 is noted to be non-ambulatory and the service plan indicates R1 will ambulate independently throughout the community. Based on administrator interviews, R1 was not at fall risk and the facility is not a medical facility where postural supports are provided by the facility. According to interviewed staff, the facility does have non-skid mats that staff will put in residents showers before giving residents a shower.

Based on observations, documents reviewed, and interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed with the administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20241210160828
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2025
Section Cited
HSC
1569.652(c)
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1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds : (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual...responsible for the fees ...within 15 days after the personal property is removed.

This requirement is not met as evidenced by:
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Licensee/administrator shall submit a plan in writing regarding how to ensure refund checks are provided in a timely manner to meet both facility's admission agreement and comply with HSC 1569.652(c).
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Based on the admission agreement reviewed and the copy of check provided for review, R1 moved out of the facility on 11/2/24 and all personal belongings were removed, however facility did not issue a refund check until 12/17/24.
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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: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5