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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 02:34:55 PM

Unsubstantiated


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
02/01/2021 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210201151221
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:
10:30 AM
MET WITH:Cristina MillerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff isolated a resident while in care
Staff prevented a resident from having access to a wheelchair while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Administrator, Cristina Miller. The investigation consisted of interviews, observations, and records review. In regard to the allegation, Staff isolated a resident while in care. Reporting Party (RP) stated Resident 1 (R1) was being isolated for up to 2 weeks after returning from the hospital. RP was not made aware that R1 was being isolated. Staff 1 (S1) stated R1 was quarantined for up to 2 weeks upon returning from the hospital while awaiting COVID test results. Facility resident notes indicated R1 was on quarantine upon returninmg from the hospital. S1 stated when R1 received a negative COVID test result, R1 was no longer quarantined. In regard to the allegation, Staff prevented a resident from having access to a wheelchair while in care. RP stated R1 did not have access to R1’s personal wheelchair and was using a facility wheelchair. S1 stated R1 did have access to a wheelchair but did not recall what wheelchair R1 was using. S1 stated R1 did have access to a wheelchair and walker while in care. Based upon interviews and information gathered, and although the 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 allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was discussed and provided to Ms. Miller.
Unsubstantiated
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)
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