331800055-4-19-2025-18-AS-RORN-DG9L4R-20250501082557

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 04/19/2025
Date Signed: 04/19/2025 06:31:00 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
10/13/2023 and conducted by Evaluator Christian Gutierrez

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20231013131810

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:	06:25 PM
MET WITH:	Jocelyn Constante - MedTech		TIME COMPLETED:	06:35 PM

ALLEGATION(S):

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Facility staff dropped resident during a transfer resulting in bruising.
Facility did not notify resident's family of incident.
Facility did not seek timely medical attention for resident.
Staff did not dispense medication according to doctor’s orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced subsequent complaint investigation visit on 04/19/2025 regarding the above allegations to deliver findings. LPA Ramirez conducted subsequent complaint investigation on 3/29/25; interviews were conducted and a needs further investigation was required. LPA Delgado conducted initial complaint visit on 10/20/2023 and a needs further investigation was documented.
The investigation consisted of the following: LPA Ramirez requested 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), Unusual/Incident Reports for R1, Hospice care notes, Resident Assessment for R1, Interview of Resident# 2- 8 (R2-R8), Interview of Staff#1- 5 (S1-S5), Attempted Interview of R1, Attempted Interview of Staff#6 (S6), Copies of S6’s: employment application, separation form, CPR/First Aid certificates, and annual training.
(Continued on LIC9099-C)

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-20231013131810

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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The investigation revealed the following: regarding the allegation- Facility staff dropped resident during a transfer resulting in bruising- It is alleged S6 dropped R1 while transporting them from their wheelchair to their bed. Five (5) out of the five (5) staff interviewed denied this allegation. Staff interviews revealed R1 had been agitated earlier that morning and staff administered a PRN to calm R1 down. Records reviewed revealed staff documented R1 was still agitated after PRN and R1’s doctor was notified. Staff interviews revealed R1 made a sudden movement forward in their wheelchair and fell out right as S6 was attempting to transfer R1 to their bed. Staff interviews did not corroborate S6 dropped R1 while transferring R1 to their bed. Eight (8) out of eight (8) residents interviewed denied this allegation. Review of hospice notes dated 9/30/2023, revealed hospice staff provided care to R1 because of a fall. Review of S6’s personnel record did not corroborate this allegation. LPA Ramirez attempted to interview R1, but R1 is no longer at the facility and unavailable for interview. 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.

Facility did not notify resident's family of incident- It is alleged facility staff did not notify R1’s family when she had a witnessed fall. Five (5) out of the five (5) staff interviewed denied this allegation. Eight (8) out of eight (8) residents interviewed denied this allegation. Records reviewed revealed staff documented R1’s fall to R1’s Power of Attorney (POA), doctor and hospice were all notified on 9/30/2023. 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.

Facility did not seek timely medical attention for resident- It is alleged facility staff did not seek timely medical attention for R1 after a witnessed fall sustained on 09/30/2023. Five (5) out of the five (5) staff interviewed denied this allegation. Eight (8) out of eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to interview R1, but R1 is no longer at the facility and unavailable for interview. Records reviewed revealed on 9/30/2023, hospice arrived after 2pm to assess R1 due to fall. Hospice notes revealed R1 was assessed and R1’s family requested to not send R1 to the hospital but wanted to keep R1 comfortable and pain free. Hospice notes and facility staff notes documented R1 had bruising to their head, left side and hand. 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.

Staff did not dispense medication according to doctor’s orders- It is alleged facility staff did not administer pain medication to R1 after witnessed fall on 09/30/2023. Five (5) out of the five (5) staff interviewed denied this allegation. Eight (8) out of eight (8) residents interviewed denied this allegation. LPA Ramirez attempted to interview R1, but R1 is no longer at the facility and unavailable for interview. Records reviewed revealed R1 had a medication order for PRN prescription for pain. Records reviewed revealed on 9/30/2023, hospice staff administered pain medication to R1 on 09/30/2023 due to a witnessed fall. 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 deficiencies were issued for this complaint investigation. Exit interview was conducted. A copy of this 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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