331800055-3-24-2023-18-AS-JESL-CR9PB8-20230426110954

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 03/24/2023
Date Signed: 03/24/2023 11:54:20 AM

Unfounded

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
03/22/2023 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230322163531

FACILITY NAME:	PACIFICA SENIOR LIVING HEMET		FACILITY NUMBER:	331800055
ADMINISTRATOR:	CRISTINA MILLER		FACILITY TYPE:	740
ADDRESS:	1177 S PALM AVE		TELEPHONE:	(951) 923-2844
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	110	CENSUS: 76	DATE:	03/24/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Executive Director Marc Pacia		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff does not ensure resident is transported to medical appointments.

INVESTIGATION FINDINGS:

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Licensing Porgram Analyst LPA) Javina George made an unaanounced visit to the facility to commence a complaint investigation regarding the allegation listed above. LPA met Marc Pacia Executive Director and explained the purpose of the visit and the elements of the allegation. The allegation Staff does not ensure resident is transported to medical appointments was investigated. The investigation consisted of observation, interviews and record review.

Regarding the allegation Staff does not ensure resident is transported to medical appointments. It was reported that Resident #1 (R1) was scheduled to have a a dentist appointment on February 23, 2023. A review of documentation showed that R1 did have a dentist appointment scheduled on March 23, 2023. Feedback provided from conducted interviews with R1 whom stated that they canceled their appointment as there was no one to accompany them. Per Executive Director Marc in the event that a resident does need additional assistance the options available would be for the resident to use their Power of attorney, hire care staff from a third party company, or family member accompany them. Additionally if the facility is not busy then there may be a staff available to accompany a resident that requires additional assistance but that is not always the case. ***Continued on 9099C

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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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Control Number 18-AS-20230322163531

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: 03/24/2023

NARRATIVE

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Due to R1 canceling their appointment before the facility not being the opportunity to assist R1 with alternative resources the allegation of Staff does not ensure resident is transported to medical appointments is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the department had there dismissed the complaint.

An exit interview was conducted and a copy of this report, 9099C and LIC 811-confidential names listed was provided to Executive Director Marc Pacia.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC9099 (FAS) - (06/04)

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