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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 08/31/2022
Date Signed: 02/26/2025 03:39:58 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
08/25/2022 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220825090051
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 89DATE:
08/31/2022
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Executive Director, Cristina MillerTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Facility did not follow resident plan to mitigate fall risk
Facility does not have adequate staffing to meet resident's needs.
Resident's hygiene needs are not being met.
INVESTIGATION FINDINGS:
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The following is an amended report: Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit to the facility to initiate an investigation into the above allegations. LPA met with Cristina Miller, Executive Director who was informed of the purposed of the visit. LPA gathered facility documentation, conducted interview, and documented observations.

Concerning allegation #1 "Facility did not follow resident plan to mitigate fall risk", LPA reviewed Resident #1 (R1)’s Needs and Services Plan as well as resident assessment with additional services being rendered. Records revealed that R1 was a total assist in toileting and required a (1) person total assist. Based on staff interviews, resident roster, and observation, the facility is comprised of cottages which are separate buildings housing up to (16) residents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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 4
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
08/25/2022 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220825090051

FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 89DATE:
08/31/2022
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Executive Director, Cristina MillerTIME COMPLETED:
06:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was not provided a pendent alarm.
INVESTIGATION FINDINGS:
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8
9
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12
13
The following is an amended report: Licensing Program Analyst (LPA) Janira Arreola made an unannounced visit to the facility to initiate an investigation into the above allegations. LPA met with Cristina Miller, Executive Director who was informed of the purposed of the visit. LPA conducted interview, and documented observations.

It was alleged “Resident was not provided a pendent alarm.” Regarding Resident #1 (R1) not having a pendant alarm. Staff interviews revealed R1 was provided with a pendant necklace they could use to summon staff, but due to R1 would remove the pendant off their person and “forget” to use it. LPA conducted an in-person interview and checked on R1 during the visit where LPA observed R1 had their pendant alarm on their person. Therefore, based on LPA observation and interviews the allegation is unsubstantiated. A finding of unsubstantiated means that although the allegation may have occurred, the preponderance of the evidence standard has not been met. An exit interview was conducted where a copy of this report was provided to Executive Director, Cristina Miller.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
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 4
Control Number 18-AS-20220825090051
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: 08/31/2022
NARRATIVE
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It was revealed through staff interviews that there was (1) caregiver in R1’s cottage when R1 had a fall in their restroom. Staff interview revealed R1 was too heavy to assist off the floor, so they called and waited for another caregiver to assist them from a neighboring cottage. Staff interviews revealed the facility mitigated R1’s fall through a call button necklace which R1 would remove off their person and “forget” to press for assistance. No additional methods of fall mitigation were revealed at the time of the visit. Therefore, based on this information the facility did not take the precautions necessary to prevent this fall. The allegation is substantiated.

Concerning allegation #2 "Facility does not have adequate staffing to meet resident's needs". Staff interviews revealing that there was (1) caregiver in R1’s cottage when they fell in their restroom. Staff interviews revealed they needed to call another caregiver to assist R1 off the floor from a neighboring cottage. Records review of R1’s Needs and Services Plan revealed R1 required total assistance for most care needs. Therefore, the facility was not adequately staffed. Therefore, the allegation is substantiated.

Concerning Allegation #3 "Resident's hygiene needs are not being met". It was alleged R1 was not assisted to the restroom when they fell at the facility. Staff interviews revealed R1 had a fall in their private restroom when attempting to relieve themselves and fell. Staff interviews revealed (1) staff was present in R1’s cottage at the time of the fall and arrived to assist R1 when they were already on the floor. Staff revealed they needed to call another caregiver to assist R1 off the floor. R1’s Needs and Services Plan revealed they required a (1) person total assist when toileting. Therefore, based the allegation is substantiated. Findings that are substantiated mean the preponderance of the evidence standard has been met. Deficiencies were cited on an LIC9099-D page.



An exit interview was conducted where a copy of this report along with LIC9099-D pages, as well as appeal rights were provided to Executive Director, Cristina Miller.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20220825090051
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: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/01/2022
Section Cited
CCR
87468.2(a)(4)
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Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Facility will submit in writting a new plan for mitigating the resident's fall risk that will meet the total assist critera needed for the resident. This will included facility plan for staffing. This will be provided to LPA by POC date.
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This requirement was not met as evidenced by: Based on observation, records review and interview,resident's care plan is not being executed as indicated with total assist for toileting, and not enough staff being present to fulfill this need. This resulting in a fall.
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CCR
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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: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4