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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 12/19/2024
Date Signed: 12/19/2024 04:03:19 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
12/10/2024 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20241210124228
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:MARK PACIAFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY:110CENSUS: 84DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Barbara Bogoje, Executive Director (ED)TIME COMPLETED:
04:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff disclosed confidential medical information of resident to an unauthorized party.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Executive Director (ED), Barbara Bogoje, and informed her of the purpose for the visit. A report was received by the Department alleging Staff One (S1) provided Resident One's (R1's) medical information to an unauthorized family member on 10/03/2024. The LPA conducted staff interviews, reviewed records, and obtained copies of relevant documentation. R1 was not available for an interview prior to the delivery of the investigation findings. S1 was interviewed and reported the individual, who was the alleged unauthorized family member, has visited R1 at the facility on at least one occasion. S1 denied providing the individual with R1's medical information. The LPA interviewed the alleged unauthorized family member; the individual reported they have visited with R1 on occasion and were denied medical information about R1 when requested. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with RSD, Miriam Issa, and a copy was provided.
NOTE: The LPA was off of the premises from about 12:20 PM to 12:50 PM.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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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