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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880550
Report Date: 02/21/2025
Date Signed: 02/21/2025 04:05:40 PM

Substantiated


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
12/24/2024 and conducted by Evaluator Seo Jeon
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20241224100529
FACILITY NAME:PACIFICA SENIOR LIVING PALM SPRINGSFACILITY NUMBER:
331880550
ADMINISTRATOR:MELISSA POLENDOFACILITY TYPE:
740
ADDRESS:1780 E BARISTO RDTELEPHONE:
(760) 322-3444
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:95CENSUS: 70DATE:
02/21/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Tammy Eddy, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not abiding to the admission agreement
Staff do not provide adequate transportation for the residents scheduled appointments
Staff did not timely repair the facility vehicle
Staff do not ensure the resident laundry needs are being met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced subsequent visit for additional investigation and met with Tammy Eddy, Executive Director. LPA informed them of the purpose of the visit. Throughout the investigation, LPA conducted resident and staff interviews, reviewed files, and records, and obtained supporting documentation to aid in determining the findings of the noted allegations. On December 24, 2024, Community Care Licensing (CCLD) received a complaint report with the following allegations.

Allegation #1 - Staff are not abiding to the admission agreement. During the LPA’s initial 10-day visit on December 26, 2024, LPA’s review of admission agreement revealed that staff did not follow some of the basic services outlined in the admission agreement, such as the following. Staff did not provide transportation or make necessary arrangements for residents’ medical and dental needs. Staff did not ensure residents’ laundry needs were met in absence of laundry staff. LPA confirmed this while conducting resident interviews.

Continued on LIC809-C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
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 6
Control Number 18-AS-20241224100529
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 PALM SPRINGS
FACILITY NUMBER: 331880550
VISIT DATE: 02/21/2025
NARRATIVE
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Allegation #2 – Staff do not provide adequate transportation for the residents scheduled appointments. Interviews with residents revealed that the facility bus has been out of service since mid-October 2024. Facility staff offered to reimburse any ride share or taxi invoices if submitted to the office, however information obtained through interviews revealed the residents did not know how. Residents who were not able to use ride share program or taxi service relied on their friends and family for transportation. 4 out 5 residents interviewed stated that they had to seek help from friends or family for transportation needs.

Allegation #3 – Staff do not timely repair the facility vehicle. An interview with the executive director revealed that the facility bus had been out of service for 2 months. LPA obtained a repair estimate for the facility bus from the executive director. Executive director was waiting for corporate headquarter to approve the bus repair.

Allegation #4 - Staff do not ensure the resident laundry needs are being met. LPA conducted review of admission agreement and confirmed the laundry service was included in the basic services provided. LPA’s interviews with residents revealed 2 out of 5 residents interviewed stated that their laundry service was skipped for one week when the laundry staff was on vacation in December 2024. Interviews with 4 staff members confirmed the laundry staff was on vacation in during that time period. Staff also stated any housekeeper would have taken care of the laundry upon request. LPA verified the laundry schedule which staff did not follow for all residents. LPA confirmed the facility did not implement an alternative laundry schedule to ensure residents laundry was done.

Based on records review, client interviews, and staff interviews, above allegations are Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.



An exit interview was conducted where a copy of this report was provided, along with a copy of LIC9099C, LIC9099D, and Appeal Rights were provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
12/24/2024 and conducted by Evaluator Seo Jeon
COMPLAINT CONTROL NUMBER: 18-AS-20241224100529

FACILITY NAME:PACIFICA SENIOR LIVING PALM SPRINGSFACILITY NUMBER:
331880550
ADMINISTRATOR:MELISSA POLENDOFACILITY TYPE:
740
ADDRESS:1780 E BARISTO RDTELEPHONE:
(760) 322-3444
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:95CENSUS: 70DATE:
02/21/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Tammy Eddy, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not properly report incidents involving the residents
Staff do not provide adequate care and supervision
Facility does not have sufficient staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced subsequent visit for additional investigation and met with Tammy Eddy, Executive Director. LPA informed them of the purpose of the visit. Throughout the investigation, LPA conducted resident and staff interviews, reviewed files, and records, and obtained supporting documentation to aid in determining the findings of the noted allegations.
On December 24, 2024, Community Care Licensing (CCLD) received a complaint record with the following allegations.

Allegation #1 - Staff do not properly report incidents involving the residents. LPA’s interview with Resident #1 (R1) revealed staff did not notify R1’s responsible party when R1 was transported to a hospital after falling in their room. LPA’s interview with R1’s responsible party confirmed R1’s statement. LPA’s interview with Executive Director revealed staff contacted R1’s responsible party in the morning of the incident and left a voice mail. Staff again called and spoke to R1’s responsible party in the afternoon of the same day.
Continued on LIC809-C....
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20241224100529
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 PALM SPRINGS
FACILITY NUMBER: 331880550
VISIT DATE: 02/21/2025
NARRATIVE
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Allegation #2 – Staff do not provide adequate care and supervision. LPA conducted review of the facility staff schedule and learned there are 6 cottages, each cottage has 2 care staff members assigned for every shift. 4 staff members interviewed expressed that there is adequate staff coverage. 4 out of 5 residents interviewed expressed that they are satisfied with the services provided and staff’s response time when call buttons were pressed.

Allegation #3 – Facility does not have sufficient staff. LPA conducted review of the facility staff schedule and learned there are 6 cottages, each cottage has 2 care staff members assigned for every shift. 4 staff members interviewed expressed that there is adequate staff coverage. 4 out of 5 residents interviewed expressed that they are satisfied with the services provided and staff’s response time when call buttons were pressed.

Based on records review, resident interviews, and staff interviews, this allegation is Unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.


An exit interview was conducted where a copy of this report was provided.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20241224100529
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 PALM SPRINGS
FACILITY NUMBER: 331880550
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87208(a)
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Section 87208 Plan of Operation (a) The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49
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New transportation vehicle is scheduled to be purchase in April 2025. All residents have been informed to contact front desk for transportation needs. Staff will set up the appointment and pay for the service.
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Based on record reviews and and interviews, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/28/2025
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility (2)The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which...
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New transportation vehicle is scheduled to be purchase in April 2025. All residents have been informed to contact front desk for transportation needs. Staff will set up the appointment and pay for the service.
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Based on record reviews and and interviews, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20241224100529
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 PALM SPRINGS
FACILITY NUMBER: 331880550
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87465(a)(2)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility (2)The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which...
1
2
3
4
5
6
7
New transportation vehicle is scheduled to be purchase in April 2025. All residents have been informed to contact front desk for transportation needs. Staff will set up the appointment and pay for the service.
8
9
10
11
12
13
14
Based on record reviews and and interviews, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
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14
Type B
02/28/2025
Section Cited
CCR
87307(a)(3)(F)
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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be... (3) Equipment and supplies necessary for personal care... (F) Basic laundry service
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Laundry schedule is made for staff to cover laundry services when the assigned attendant is absent.
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Based on record reviews and and interviews, the licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6