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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 03:51:07 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
11/26/2019 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191126141614
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:MONYA HENRYFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 216-3932
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 71DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Barbara Bogoje - Resident Services DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Lack of supervision resulting in resident falling.

Resident sustained an injury while in care.

There are not enough staff scheduled to meet residents' needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Colvin arrived at the facility unannounced (after conducting a COVID-19 Risk Assessment via telephone) to deliver the findings for the complaint investigation with the above allegation. LPA spoke with Resident Services Director Barbara Bogojeand explained the purpose of the call. Findings are as follows:

Regarding allegation "Lack of supervision resulting in resident falling": During the investigation of this complaint, LPA Colvin discovered that Resident #1 (R1) had a long and well documented history of both falls and being a fall risk. In 2019 alone, R1 sustained no less than 12 falls, the majority of which resulted in R1 being sent to the hospital. Despite the numerous falls and trips to the hospital, the facility failed to institute additional fall protections for R1, despite having had discussions addressing the possible need for additional care. On 11/23/19, R1 sustained another fall in the facility which was not observed by staff, and when interviewed, no one could be sure of when R1 had last been seen safely in bed. Therefore, based on record review and interviews, the allegation "Lack of supervision resulting in resident falling" is SUBSTANTIATED.
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 4
Control Number 18-AS-20191126141614
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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Regarding allegation "Resident sustained an injury while in care": Review of R1's medical records from R1's hospitalization from their fall at the facility on 11/23/19 revealed that R1 sustained numerous bruises all over R1's body, as well as a facial hematoma which required medical attention. LPA Colvin received photographs of the bruises on R1 as well and confirmed that they covered a large portion of R1's extremities and face. Upon discharge from the hospital, R1 was re-evaluated by their physician and a new Physician's Report (11/27/19) was created, wherein R1's physician noted that R1 had since declined from being non-ambulatory to bedridden, and that R1 would not be able to be out of bed again "for weeks, if at all". Therefore, based on the large amount of bruising sustained by R1 as well as the significant decline in condition after the fall, the allegation of "Resident sustained an injury while in care" is SUBSTANTIATED.

Regarding allegation "There are not enough staff scheduled to meet residents' needs": In LPA Colvin's investigation of this allegation, LPA Colvin reviewed facility records including staff schedule, resident roster, and resident alarm calls & response times. LPA Colvin observed that during the late night shift (NOC shift), there are regularly only two caregivers that cover all four Assisted Living cottages, and on several occasions (11/2/19, 11/3/1911/6/19 & 11/12/19) there is only one caregiver to all four cottages during the NOC shift. LPA Colvin additionally learned through investigation that the facility's NOC Medical Technician is utilized to aid the Memory Care caregivers with reliving them of their breaks, but there is no additional relief staff for the NOC caregivers for Assisted Living. Therefore, if no one calls off of work and all staff scheduled are present, while one of the two NOC Assisted Living caregivers take their lunch break, the other must watch over the other's two cottages, totalling for one caregiver to four cottages. LPA Colvin additionally reviewed a sample of the resident alarm calls and response times and calculated the percentage of calls which were not responded to in under 10 minutes. LPA Colvin observed that 100 of 392 calls for a single cottage over the course of 30 days were not responded to in under 10 minutes. LPA Colvin additionally analyzed the shifts in which these longer response times were taking place, and LPA Colvin observed that 41% of the calls which took over 10 minutes for staff to respond to occurred during the NOC shift. Therefore, based on review of staff scheduled and resident alarm calls and response times, the allegation "There are not enough staff scheduled to meet residents' needs" 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.

An exit interview was conducted where this report and appeal rights were discussed. A copy of this report, LIC9099Ds, and appeal rights was 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: 4 of 4
Control Number 18-AS-20191126141614
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 that residents are regularly observed for changes...and that appropriate assistance is provided...licensee shall ensure that such changes are documented and brought to the attention of...physician and...responsible person...This was not met by:
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Licensee has conducted an all-staff meeting and expressed expectation that NOC staff are to visually inspect residents during rounds to ensure safety and wellness. Additionally, Licensee has instituted that staff are to monitor residents with incontinence more closely during the night. No POC needed.
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Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 had sustained 12 falls in 2019 alone yet no additional protective measures were taken for R1 despite this need being identified. This was an immediate safety risk to R1.
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Type A
09/17/2021
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights...in Privately Operated Facilities: (a) In addition to the rights listed...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by:
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Licensee agrees to address changes in all residents' conditions and follow through with observed unmet needs through updated Needs & Services Plans as well as taking neccesary actions (such as possible eviction) to ensure adequate level of care. No further POC needed.
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Based on record review and interviews, the Licensee did not comply with the above regulation with R1. On 11/23/21, R1 suffered from an unwitnessed fall in the facility, which resulted in bruising on most of R1's extremeties and facial hematoma. This was 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: 3 of 4
Control Number 18-AS-20191126141614
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 B
10/01/2021
Section Cited
CCR
87415(a)(3)
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Night Supervision: (a) The following persons providing night supervision...shall...be available as indicated below to assist in caring for residents... (3) In facilities caring for one hundred one (101)...residents...one employee shall be on call and capable of responding within ten minutes. This was not met by:
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Licensee agrees to conduct audit of resident alarm response times for all cottages for a 30 day period and compare with staff scheduling to identify any unmet needs. Findings of audit to be provided to LPA Colvin by Plan of Correction date of 10/1/21 as well as plan for addressing any needs identified in audit.
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Based on record review, the Licensee did not comply with the above regulation with at least one shift (NOC). LPA Colvin observed the NOC shift to only have two caregivers to four cottages, and at times, one caregiver to four cottages. Response times show excess of ten minutes. This is a potential personal rights risk.
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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 4