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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 03/29/2025
Date Signed: 03/29/2025 05:25:25 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
01/10/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230110093308
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: 94DATE:
03/29/2025
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Resident Assistant Yulma BallesTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/29/2025 regarding the above allegation. LPA Mixon conducted initial complaint visit on 01/13/2023 and a needs further investigation was documented. During today’s visit, LPA Ramirez was greeted by Staff-Brittney Walsh and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1 - 5 interviews (S1 – S5), Attempted interview of Resident#1 (R1) Resident#2-9 interviews (R2-R9), copies of Resident#1 (R1)- face sheet, emergency contact information, Centrally Stored Medications (LIC 622), Controlled Medications Record, Prescription Orders for R1, Physician’s Report (LIC 602), and physical plant tour.

See 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2025
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 2
Control Number 18-AS-20230110093308
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: 03/29/2025
NARRATIVE
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The investigation revealed the following. Regarding Allegation: Staff did not administer resident's medication as prescribed – It is alleged on 01/10/2023, R1’s medications were discontinued by the facility physician. Five (5) out of the five (5) staff interviewed denied this allegation. Seven (7) out of the eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to contact R1 for an interview, but R1 was not available for an interview. LPA Ramirez reviewed R1’s facility file and it revealed R1 was admitted into the facility in August of 2021. Review of R1 Physician’s report dated 01/05/2023, revealed R1’s physician documented R1 was non-compliant with medication recommendations. Review of R1’s Physician’s report dated 02/21/2023, revealed R1’s physician noted R1 was “Resistant to medication management and wants to choose what medications to take and never accepts medical advice.” LPA Ramirez reviewed a prescription medication change order by R1’s physician dated 01/06/2023. On 1/6/2023, R1’s physician ordered R1 discontinued twelve (12) medications and ordered R1 be administered four (4) new medications. Staff interviewed revealed medication technician's administer and or discontinue medications according to the physician's order. 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.

No violations were cited for this investigation. Exit interview was conducted. A copy of this report was provided via email.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2