331800055-4-19-2025-18-AS-RORN-DFYP9Q-20250422110732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 04/19/2025
Date Signed: 04/19/2025 06:14:54 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
05/03/2024 and conducted by Evaluator Christian Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240503151502

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: 80	DATE:	04/19/2025
		UNANNOUNCED	TIME BEGAN:	08:56 AM
MET WITH:	Executive Director Barbara Bogoje		TIME COMPLETED:	06:25 PM

ALLEGATION(S):

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Facility issued a rate increase for a falsiflied change of condition
Facility falsified paperwork

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Barbara Bogoje Resident Service Director and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 05/07/2024, LPA Delgado interviewed one (1) staff and requested and obtained copies of documentation. During today’s visit LPA Gutierrez interviewed Resident Service Director/Administrator, staff #1- Staff #3 and resident #2 -resident #9. Resident one R1 has left facility. LPA obtained copies of the following documents: staff roster, resident roster, R1’s admission agreement, physicians reports, identification and emergency information, and resident assessment.
SEE LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2025

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-20240503151502

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: 04/19/2025

NARRATIVE

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In regard to the allegation “Facility issued a rate increase for a falsified change of condition”, it is alleged that a change of condition was given that was not needed for R1 therefore a rent increase was issued for services not needed. During interviews with residents eight (8) out of the nine (9) residents stated that they have never received a rate increase that they didn’t know about. R7 stated that everything goes up, but they are always given notification of an increase. During interviews with Administrator and staff all four (4) stated that all residents and person responsible for residents are notified of any rate increase. Administrator stated that the nurse and physicians make the assessment if any change of condition has occurred and base the rate on the type of care residents need. During file review LPA observed that there was a change of condition for R1.

In regard to the allegation” Facility falsified paperwork”, it is alleged that the signature on signed contract is falsified. During interviews with administrator and staff four out (4) out of five (5) staff state that they have never heard of any falsified documentation. During interviews with residents eight (8) out of nine (9) stated they have had no issues with their contracts to their knowledge. LPA reviewed admission agreement and resident assessment documentation and were all signed by both resident and responsible party LPA found no discrepancies.

Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. 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 Med-Tech Jocelyn Constante. A copy of the report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2025

LIC9099 (FAS) - (06/04)

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