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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 02:45:54 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
05/06/2021 and conducted by Evaluator Jennifer Semin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210506134150
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:
01:00 PM
MET WITH:Cristina MillerTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not ensure that resident's hearing aide is charged.
Staff do not ensure that resident has writing utensils
Staff do not safe guard resident's personal items
INVESTIGATION FINDINGS:
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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 do not ensure that resident's hearing aids are charged. Reporting Party (RP) indicated Resident 1’s (R1) hearing aids are not being charged properly. Staff 1 (S1) stated R1 used to unplug their hearing aids and place them in their dresser. S1 and POA stated it was decided that the hearing aids would be charged by staff in the wellness center. LPA observed R1 wearing hearing aids and responding to questions. R1 knew where the charger is located, and that staff charge them every night. LPA observed the charger in the wellness center.
In regard to the allegation, Staff do not ensure that resident has writing utensils. RP stated R1 never has access to writing utensils. S1 stated there are pens, pencils, and paper available to all residents and R1 keeps paper and pencils in their dresser. LPA observed a central area for paper, pens and pencils that is accessible to residents in care. R1 showed LPA their stock of paper and pencils.
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)
Page: 1 of 2
Control Number 18-AS-20210506134150
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: 05/12/2022
NARRATIVE
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In regard to the allegation, Staff do not safeguard resident's personal items. RP stated staff are taking R1’s wine away from them. S1 stated R1 does get bottles of wine from a family member about once a week or once every two weeks. R1 stated she gets a glass of wine from staff every day. R1 stated staff have her wine in the refrigerator. LPA observed R1’s wine labeled and stored in a refrigerator that is inaccessible to residents 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.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2