<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 10/15/2021
Date Signed: 10/15/2021 11:29:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/12/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211012124015
FACILITY NAME:PACIFICA SENIOR LIVING RIVERSIDEFACILITY NUMBER:
336425840
ADMINISTRATOR:EVA TAWFIKFACILITY TYPE:
740
ADDRESS:6280 CLAY STREETTELEPHONE:
(951) 360-1616
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:110CENSUS: 86DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Eva TawfikTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not properly report an incident involving a resident while in care
Staff did not document change in physical condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA identified herself and met with Administrator, Eva Tawfik. LPA discussed the purpose of the visit with Tawfik. The investigation consisted of records review, direct observation, and interviews with staff and residents.

In regards to allegation #1, LPA interviewed Staff #1 (S1) who stated that Resident #1 (R1) had sustained a bruise to the forehead from an unknown origin. Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4) also confirmed that R1 sustained a bruise to the forehead. S1 stated that the bruises were first brought to their attention by R1's daughter who noticed the bruise during a facility visit. However, S3 stated that they observed the bruise while attending to R1 and reported it to S4. S4 stated that the bruise was then reported to S1. S1 stated that they first learned of R1's bruise from R1's daughter, not facility staff. S1 also stated that there was no incident report sent to the Department regarding the bruise to R1's forehead. S2 also confirmed that there was no
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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 5
Control Number 18-AS-20211012124015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE
FACILITY NUMBER: 336425840
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2021
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical... the licensee shall ensure that such changes are documented and brought to the attention.. and the resident's responsible person. This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
The Administrator agreed to conduct training for all staff on section 87466- Observation of the Resident of the California Code of Regulations and send proof to the Department by POC date of 10/22/2021.
8
9
10
11
12
13
14
Based on interviews and records review, the facility could not produce documentation regarding R1's bruise to the forehead. However, during interviews conducted by LPA, 2 of 4 (S3 & S4) staff members interviewed stated that they observed the bruise prior to S1 learning of the bruise from R1's daughter.
8
9
10
11
12
13
14
Type B
10/22/2021
Section Cited
CCR
87211(a)(1)(B)
1
2
3
4
5
6
7
87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency .. (1)A written report shall be submitted to the licensing agency ..(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
The Administrator agreed to conduct training for all staff on section 87211- Reporting Requirements of the California Code of Regulations and send proof to the Department by POC date of 10/22/2021.
8
9
10
11
12
13
14
Based on interviews and records review, 2 of 4 staff members (S1 & S2) stated that there was no incident report was sent to the Department. LPA also reviewed incident report log and did not observe incident report regarding R1's bruise submitted to the Department.
8
9
10
11
12
13
14
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: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 18-AS-20211012124015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE
FACILITY NUMBER: 336425840
VISIT DATE: 10/15/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
incident report sent to the Department regarding R1's bruise. LPA reviewed the Department's incident report log and did not observe that an incident report regarding R1's bruise was reported to the appropriate regional office. S1 confirmed that they first learned of R1's bruise from R1's daughter; not facility staff; therefore, the incident was not properly reported to the Department and responsible party.

In regards to allegation #2, LPA interviewed S1 who stated that they when they first learned of R1's bruise, they could not find documentation/notes of the incident so S1 stated that they conducted interviews with facility staff of the origin of R1's bruise. LPA reviewed the facility's "Narrative Chart" which did not indicate that facility staff observed a bruise on R1's forehead as stated by S2 and S3.





SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/12/2021 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211012124015

FACILITY NAME:PACIFICA SENIOR LIVING RIVERSIDEFACILITY NUMBER:
336425840
ADMINISTRATOR:EVA TAWFIKFACILITY TYPE:
740
ADDRESS:6280 CLAY STREETTELEPHONE:
(951) 360-1616
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:110CENSUS: 86DATE:
10/15/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Eva TawfikTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/lack of supervision resulting in resident sustaining bruising
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to deliver findings for the above allegations. LPA identified herself and met with Administrator, Eva Tawfik. LPA discussed the purpose of the visit with Tawfik. The investigation consisted of records review, direct observation, and interviews with staff and residents.

LPA interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and Staff #4 (S4), who all denied that neglect/lack of supervision resulted in Resident #1 (R1) sustaining a bruise to the forehead. S1 and S2 stated that an internal investigation of how R1 sustained the bruise was conducted; however, they could not determine an origin. S4 stated that they conducted an assessment of R1's bruise to the forehead and could not determine the source; however, S4 stated that R1 did not complaint of pain or discomfort. LPA attempted to interview R1; however, LPA could not retrieve a statement due to R1's health condition.

Based on evidence obtained during today’s visit, LPA has determined that the above allegation is
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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 5
Control Number 18-AS-20211012124015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE
FACILITY NUMBER: 336425840
VISIT DATE: 10/15/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
UNSUBSTANTIATED; meaning that 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.

An exit interview was conducted where this report was discussed and a copy was provided to Tawfik at the conclusion of the investigation.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5