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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 02/21/2025
Date Signed: 02/21/2025 01:32:16 PM

Substantiated


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
01/09/2025 and conducted by Evaluator Abdoulaye Zerbo
COMPLAINT CONTROL NUMBER: 18-AS-20250109093446
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: 80DATE:
02/21/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Barbara BogojeTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abdoulaye Zerbo made an unannounced follow-up complaint visit to the facility to deliver findings on the above allegations. LPA met with Executive Director (ED) Barbara Bogoje, explained the purpose of the visit, and was granted entry into the facility.
It was alleged that the facility is in disrepair. All six (6) cottages, including the kitchen area, were toured during the inspection. The kitchen was observed to be clean and fully functional. Five (5) of the six (6) cottages were in good condition. One cottage in memory care had a hole in the ceiling in the laundry room. Maintenance and the Executive Director (ED) acknowledged the issue and confirmed that repairs were underway.
Based on the evidence, the allegation mentioned above is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the preponderance of the evidence standard has been met.

Deficiencies were cited on an LIC9099- D page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
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
Control Number 18-AS-20250109093446
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:

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The licensee must ensure repairs are made with proof of repair to licensing by the POC due date
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Based on observation and interview, the ceiling in the laundry room of one(1) of the memory care cottage had a hole, which poses a potential health, safety or personal rights risk to persons in care.
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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: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
01/09/2025 and conducted by Evaluator Abdoulaye Zerbo
COMPLAINT CONTROL NUMBER: 18-AS-20250109093446

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: 80DATE:
02/21/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Barbara BogojeTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility did not ensure residents were provided with adequate emergency lighting
Staff did not ensure a safe environment was provided to residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abdoulaye Zerbo made an unannounced follow-up complaint visit to the facility to deliver findings on the above allegations. LPA met with the Executive Director (ED) Barbara Bogoje, explained the purpose of the visit, and was granted entry into the facility.
It was alleged that the facility did not ensure residents were provided with adequate emergency lighting. LPA interviewed five (5) residents and four (4) staff members. Three (3) out of five (5) residents said they were not provided any lighting during the outage. The remaining two (2) residents were not sure if they were provided any lighting. Four (4) out of four (4) staff members stated most of the residents had neon lights in their rooms, and they made sure they had enough batteries as well. LPA conducted a tour and observed one flashlight in one of the assisted living cottages next to the fire extinguisher. LPA asked (ED) about the rest of the flashlights, and they stated they did not know, and they were assuming the staff may have taken it home.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20250109093446
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: 02/21/2025
NARRATIVE
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It was alleged that the staff did not ensure a safe environment was provided to residents in care. Five (5) of five (5) staff members interviewed stated all staff working during the outage took fast action to make sure all the residents were safe. In the memory care cottages, staff stated they were provided with flashlights, and residents were provided with extra blankets. LPA also observed a box containing multiple lanterns to be available. The staff also stated all the residents were gathered in the dining area and did activities with them. They also stated one (1) staff was positioned at each exit to ensure no clients were going out unsupervised. At the Assisted Living cottages, LPA observed the call button to be battery operated and in good repair. staff stated they were provided with flashlights to ensure care and supervision would not be interrupted and or jeopardized due to the power outage. LPA observed a few rooms to have lanterns. The ED stated all the families, as well as hospice companies, were notified during the power outage.

Based on the evidence, the allegation mentioned above is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4