331800055-5-10-2025-18-AS-RORN-DHQP2N-20250617105611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800055
Report Date: 05/10/2025
Date Signed: 05/10/2025 03:24:35 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
01/18/2024 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240118084146

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: 72	DATE:	05/10/2025
		UNANNOUNCED	TIME BEGAN:	12:21 PM
MET WITH:	Brittney Walsh/Miajoy Mc Elyea		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff did not make sure residents have their dinner.
Staff left residents in soiled bedding or briefs.
Staff did not make sure resident’s restroom was clean.
Staff dd not answer resdients call pendants in a timely fashion.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Weslety conducted an unannounced complaint visit to investigate the above allegations. LPA Wesley met with Community Relations Director Brittney Walsh to explained the purpose for todays visit. Brittney included Resident Service Director Miajoy Mc Elyea to join the visit.

The investigation consisted of the following: LPA toured the community, obtained copies of staff roster, client roster, faciltiy menu, tested residents call buttons. LPA interviewed 8 out of 9 residents, and 5 staff.

Regarding allegation: Staff did not make sure residents have their dinner. Dinner is served in each of cottages dining area at 4:30pm. A resident can eat in the dining area or in their room. When its time for
dinner, the resident are told its dinner time and for those they are in a wheelchair and require assistance, they are taken the dining area. LPA Wesley interviewed 8 residents who said the staff makes sure they have their dinner.
continued on LIC9099C. M

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

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-20240118084146

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: 05/10/2025

NARRATIVE

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Regarding allegation: Staff left residents in soiled bedding or briefs. LPA Wesley Interviewed 8 residents who said they are never left in soiled bedding or briefs and LPA Wesley interviewed Staff #1 who said she ensures staff meets the schedule for changing the residents briefs which is every two hours or as needed, depending on the residents level of care. Staff #1 said when a resident takes their shower their bedding is changed, some residents require more changes than the other depending on how often the bed is wet.

Regarding allegation: Staff did not make sure resident’s restroom was clean. LPA Wesley interviewed staff #1 who said the residents rooms are lightly cleaned daily, they caregivers take the trash out, dust and clean the residents bathroom. LPA Wesley interviewed residents 1-8 and they did not have a problem with their bathroom being cleaned or their trash being emptied by the staff or hospice providers. One resident said she takes out her own trash to have something to do. Staff #1 said she hasn't heard any problems with the staff not doing their duties.

Regarding allegation: Staff did not answer residents call pendants in a timely fashion. LPA Wesley toured 2 of the resident cottages and pressed the pendants of the residents neck and the residents night stand, and the staff answered it within a decent time frame. LPA Wesley interviewed 8 residents who said their call pendants are answered, sometimes it could take longer depending on what they are doing for other residents. LPA Wesley asked what's the longest time you had to wait, and it was under 20 minutes. LPA Wesley asked staff do they answer call pendants in a timely manner and they answered yes it is usually 30 minutes or less depending on what the resident is calling for.

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.

A copy of the LIC 809/809C was given during the exit interview.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Nicol Wesley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

LIC9099 (FAS) - (06/04)

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