331800055-4-5-2025-18-AS-RORN-DH3MNL-20250527094543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 04/05/2025
Date Signed: 04/05/2025 01:36:42 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 Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20241210124228

FACILITY NAME:	PACIFICA SENIOR LIVING HEMET		FACILITY NUMBER:	331800055
ADMINISTRATOR:	MARK PACIA		FACILITY TYPE:	740
ADDRESS:	1177 S PALM AVE		TELEPHONE:	(951) 923-2844
CITY:	HEMET	STATE: CA	ZIP CODE:	92543
CAPACITY:	110	CENSUS: 84	DATE:	04/05/2025
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Brittany Walsh, Sales Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility staff subjected resident to multiple doctor visits due to staff refusing to accept physician diagnosis.
Resident sustained an injury from an unwitnessed fall due to lack of supervision.
Facility staff did not notify resident’s authorized representative of resident’s injury.
Facility is not reporting contagious outbreak to residents and/or their authorized representatives.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a follow-up visit to deliver findings. LPA met with Staff, Brittany Walsh, and explained the reason for the visit.

The investigation consisted of the following:
On 12/19/24, LPA Stephanie Martinez started the complaint investigation and interviewed one staff, requested copies of relevant documentation, and toured two of six buildings. The allegations needed a further investigation. On 4/4/25, LPA Chan conducted a follow-up visit to interview the administrator, 5 Staff, and 9 residents. Resident #1 is no longer residing at the facility and was not interviewed.

The investigation revealed the following:
Allegation - Facility staff subjected resident to multiple doctor visits due to staff refusing to accept physician's diagnosis. It is alleged that the staff kept insisting Resident #1 (R1) had scabies.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2025

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-20241210124228

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: 04/05/2025

NARRATIVE

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LPA reviewed R1’s facility file. Upon admission, R1 had a general body rash and dermatitis. After summary reports on file from 8/16/24 – 10/24/24 indicated that R1 had either a bacterial skin condition or dermatitis. Staff interviewed stated they suspected R1 to have scabies due to increased itch and observation of skin. R1’s family member agreed to take resident to the doctor’s appointments. The after summary reports did not mention scabies, however, it was noted that on 9/18/24, the doctor prescribed Permethrin cream to treat dermatitis. Staff indicated that the family member later called and reported that R1 has scabies while at the hospital.

Allegation - Resident sustained an injury from an unwitnessed fall due to lack of supervision. It is alleged that Resident #1 (R1) fell and sustained a bruise to the hip area down to the calf. Staff and Residents were interviewed regarding this allegation. The administrator stated there are 2 care staff per shift in the memory care unit and 1 care staff and a med tech in the other cottages. Staff indicated they are frequently checking on the resident, at least 1 to 2 hours. Staff stated that when a resident falls, they contact the med tech to inform them of the fall. The med tech and Resident Care Coordinator will assess the resident and contact 911. Regarding R1, Staff stated that the resident had fallen while at the facility. However, staff attended to the resident and assessed right away. Per resident interviews, staff are always supervising residents and those who have fallen at the facility were helped immediately.

Allegation - Facility staff did not notify resident’s authorized representative of the resident’s injury. LPA Chan interviewed the administrator and staff regarding this allegation. Per administrator and staff, anytime there is a fall or injury to a resident, they would contact the authorized representative to inform them of the incident. Care staff stated that they do not notify families of the incident. The administrator, resident care coordinator, or med techs are responsible for notifying the authorized representatives. Per staff, R1’s authorized representative was notified of all known falls and/or injuries. Five of the residents interviewed indicated that their families are notified if anything happens to them.

(Continue on LIC9099C)

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20241210124228

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: 04/05/2025

NARRATIVE

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Allegation - Facility is not reporting contagious outbreak to residents and/or their authorized representatives. It is alleged that the scabies outbreak was not reported to the residents and their authorized representatives. The administrator and staff stated that the scabies outbreak was reported to the public health department, licensing, residents, and authorized representatives. The outbreak occurred back in November 2024 in the memory care unit. LPA observed a line list of residents with the onset of scabies symptoms and the doctor’s diagnosis. Per the administrator, there was no letter provided by the public health department. Staff stated they notified the all the families/authorized representatives via telephone and the affected residents’ physicians. They also stated visitors were informed of the outbreak during visitations.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Staff B. Walsh. A copy of this report, along with the appeal rights, was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2025

LIC9099 (FAS) - (06/04)

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