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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 05/12/2022
Date Signed: 05/12/2022 02:32:40 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
08/14/2020 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200814160100
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:MONYA HENRYFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 83DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cristina MillerTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility has mold in walk-in refrigerator
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegation. LPA met with Administrator, Cristina Miller. The investigation consisted of interviews, observations and records review. In regard to the allegation, Facility has mold in walk-in refrigerator. Reporting Party (RP) stated there was mold present in the walk-in refrigerator while RP was on staff at the facility in August 2020. Staff 1 (S1) stated the walk in did have an ongoing mold problem. S1 provided documents dated November 2021 and March 2022 for repairs to the walk in.. S1 stated prior to that kitchen staff did not indicate there was a mold issue. S1 did not discover the mold issue until new staff alerted S1 to the problem. Staff 2 (S2) stated there was mold present in the walk in in January 2022 through March 2022. LPA observed the walk in refrigerator to be free of mold.
Based on the evidence gathered during the investigation, the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where this report (LIC 9099 & LIC 9099C) was discussed with the Ms. Miller.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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 18-AS-20200814160100
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: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2022
Section Cited
CCR
87411(a)
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Personnel Requirements - General:
Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section
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LIcensee shall read the requlation in it's entirety, train staff on regulation, submit a statement of understanding and training log to CCL by the POC due date of 5/13/2022.

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87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. This requirement was not met as evidenced by: Kitchen staff did not report, to management, of potentially dangerous mold in the kitchen walk-in refrigerator. This poses a health and safety risk to residents 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: Karen Clemons
LICENSING EVALUATOR NAME: Jennifer Semin
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2