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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 08/05/2024
Date Signed: 08/05/2024 12:05:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
08/16/2021 and conducted by Evaluator Sara Martinez
COMPLAINT CONTROL NUMBER: 18-AS-20210816150952
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: 76DATE:
08/05/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Continuous Improvement Specialist Kim Henson TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident fell while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Continuous Improvement Specialist Kim Henson and explained the purpose of the visit.

Regarding allegation “Resident fell while in care”, it was reported Resident One (R1) had fallen while in care due to lack of supervision by staff and sustaining an injury as a result of the fall. Interview with staff revealed Staff One (S1) observed R1 in the living room in their wheelchair. S1 returned to the living room from the kitchen and found R1 on the floor. S1 attempted first aid to the back of the head and contacted two (2) staff for assistance. Records review of staff schedule revealed two caregivers and one MedTech were scheduled to work the PM shift on 08/11/2021. Records review of facility’s Narrative Charting revealed R1 sustained a laceration to the back of the head and R1 was transported to the hospital. R1 was admitted to the facility on 08/10/2021 with resident assessment of ambulation with one (1) person total assist or wheelchair escort to and from activities, meals, etc.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
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-20210816150952
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055
VISIT DATE: 08/05/2024
NARRATIVE
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Interview with R1 was not conducted due to R1’s passing in August 2021.

Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Continuous Improvement Specialist Kim Henson.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Sara Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2