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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 09/16/2021
Date Signed: 09/16/2021 03:49:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2019 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191025145503
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:JONETTE EADSFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 216-3932
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 71DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Barbara Bogoje - Resident Services DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Resident was hospitalized for dehydration
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Colvin arrived at the facility unannounced to deliver the findings for the complaint investigation with the above allegation. LPA spoke with Resident Services Director Barbara Bogoje and explained the purpose of the call. Findings are as follows:

Regarding allegation "Resident was hospitalized for dehydration": On 10/12/19, Memory Care resident (R1) was transported to the hospital by their family, where R1 was admitted and diagnosed with Dehydration, Urinary Tract Infection (UTI) and Acute Renal Failure. R1 was hospitalized for three days and was treated with IV fluids and antibiotics. During the intake assessment at the hospital, R1 was observed to be oriented to name only, and could not recall the date, where R1 was, or the purpose for being there. Additionally, hospital staff observed R1 to be weighing 180 pounds, 20 pounds less than R1's average weight (per documentation in facility records and past Physician's Reports). LPA Colvin reviewed the facility's records and confirmed that facility staff documented a sudden weight loss back on 9/4/20, but neither R1's family nor R1's physician were notified of the sudden weight loss.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2019 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191025145503

FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:JONETTE EADSFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 216-3932
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 71DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Barbara Bogoje - Resident Services DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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8
9
Residents have unexplained bruising

Food service is inadequate
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Colvin arrived at the facility unannounced to deliver the findings for the complaint investigation with the above allegation. LPA spoke with Resident Services Director Barbara Bogoje and explained the purpose of the call. Findings are as follows:

Regarding allegation "Residents have unexplained bruising": For this investigation, interviews were conducted with facility staff, Hospice, and private caregivers retained by the resident's (R3) family, as well as review of the facility's file for R3, including R3's medication and Needs and Services Plan. R3's Needs and Services Plan states that R3 is a two-person lift, which was implemented at the request of R3's family, as they observed R3 had sustained bruising around the arms and hands. In the interviews conducted, all parties acknowledged knowing that R3 is a two-person assist, and that there have been concerns noted by family regarding the bruising. Staff at the facility all stated that they follow the two-person assist with R3, though they additionally noted that at least one of the private caregivers retained by the family (O1), does not follow the two-person assist protocol, which O1 openly admitted to.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20191025145503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055
VISIT DATE: 09/16/2021
NARRATIVE
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It was additionally noted that R3 was on a blood thinning medication (Plavix) which is known to cause its users to be easily susceptible to bruising. Side effects regarding this medication and R3's bruises were discussed with R3's doctor, who confirmed that the medication causes patient to easily bruise and even experience sub-dermal bleeding. Based on record review and interviews conducted, the allegation of "Residents have unexplained bruising" is UNSUBSTANTIATED.

Regarding allegation "Food service is inadequate": LPA Colvin reviewed the facility's Dietary Quarterly Quality Assurance Reports for the last 12 months, as well as the sample menu provided by the Administrator to LPA Colvin. LPA Colvin observed that in the Quarterly Reports (which are conducted by Registered Dietician from outside of the facility) the facility has maintained an "A" grade, with 100% rating for Meal Service and Nutritional Assessment in the last 4 reports. LPA Colvin additionally observed that the facility was docked a few points from their score in Sanitation for minor errors, which do not correlate with the concern in the complaint, which is specific to the portions of the food being served being inadequate. Based on record review, the allegation of "Food service is inadequate" is UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted, and a copy of this report was provided to Resident Services Director Barbara Bogoje.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2019 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191025145503

FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:JONETTE EADSFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 216-3932
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 71DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Barbara Bogoje - Resident Services DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Resident developed a bed sore while in care of facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Colvin arrived at the facility unannounced to deliver the findings for the complaint investigation with the above allegation. LPA spoke with Resident Services Director Barbara Bogoje and explained the purpose of the call. Findings are as follows:

Regarding allegation "Resident developed a bed sore while in care of facility": Facility records state that a Memory Care Resident (R2) developed a Stage 2 pressure injury on R2's coccyx, which was first observed by facility staff on 9/27/19. Hospice Records reviewed by LPA Colvin show that R2 has been on Hospice since 5/9/17, which is prior to the date of the pressure injury. Hospice records additionally show that R2 was being treated for a pressure injury to R2's coccyx since 8/29/19 by Hospice care staff. Further review of R2's Hospice records show that Hospice care staff continued to treat R2's pressure injury up until R2's passing on 11/8/19, with the last date of Hospice having gone to the facility to provide wound care on 11/5/19, when all medications were discontinued and comfort-only measures were put into place as R2 was actively dying.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20191025145503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055
VISIT DATE: 09/16/2021
NARRATIVE
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LPA Colvin reviewed R2's history of care at the facility and observed that R2 had a history of developing pressure injuries, and with the assistance of wound care from Hospice, R2's pressure injuries tended to heal. R2's Hospice records show that the nurses from Hospice that would treat R2's pressure injury would consistently communicate with facility staff, provide training and instruction, and order additional supplies (such as low air loss mattress) for R2 in order to attempt to treat R2's worsening pressure injury. Therefore, due to interviews and record review, the allegation of "Resident developed a bed sore while in care of facility" is UNFOUNDED.

We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted, and a copy of this report was provided to Resident Services Director Barbara Bogoje.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 18-AS-20191025145503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2021
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure...residents are...observed for changes...When changes...are observed, the licensee shall ensure that such changes are...brought to the attention of the resident's physician...and responsible person, if any.
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Licensee conducted a meeting with all staff regarding procedures for resident weight changes and when resident's skip a meal. Additionally, the Memory Care Director has taken over responsiblity for weighing residents. No further POC needed.
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This requirement was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation. R1 lost 23 pounds and had symptoms, and was nott given prompt medical attention. This posed an immediate health risk to R1.
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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: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20191025145503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055
VISIT DATE: 09/16/2021
NARRATIVE
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In LPA Colvin's interviews, R1's weight loss was attributed to R1 not eating or drinking for long periods of time, yet during LPA Colvin's review of the facility records, LPA Colvin observed that this was not documented in any documentation provided to LPA Colvin, nor in any documented correspondence to R1's physician. In LPA Colvin's investigation of the allegation, LPA Colvin confirmed that R1 was hospitalized for dehydration in addition to other medical concerns, all of which were unobserved by facility staff, who failed to adequately document the R1's changing condition or seek timely medical attention for the resident. Due to LPA Colvin's review of the facility's file, the resident's medical records, and interviews, the allegation of "Resident was hospitalized for dehydration" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to investigation that was conducted by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 D. An exit interview was conducted with Resident Services Director Barbara Bogoje where this report and appeal rights were discussed. A copy of this report, LIC 9099D, and appeal rights were provided to Resident Services Director Barbara Bogoje during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7