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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:47:12 PM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/24/2023 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231024105428
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:
10/26/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Eva Tawfik, Executive DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Due to staff negligence, resident has an unexplained bruise

Staff is not allowing resident to have visitors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to investigate the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Executive Director Eva Tawfik. The investigation consisted of a facility tour, resident interviews, staff interviews, and document review.

For allegation, Due to staff negligence, resident has an unexplained bruise :
Interviews with staff and documentation revealed that resident #1 (R1) did have a fall and was witnessed by staff. The fall was documented and the responsible party notified. R1 did sustained a bruise, which is explained in detail in the incident report obtained during today's investigation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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 2
Control Number 56-AS-20231024105428
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
, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE
FACILITY NUMBER: 336425840
VISIT DATE: 10/26/2023
NARRATIVE
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For allegation, Staff is not allowing resident to have visitors :

LPA interviewed R1's responsible party, who has instructed facility staff to only limit visitations to the responsible party, who is also R1's Power of Attorney (POA). Interviews with staff and POA state the visitations from other parties, aggravate R1 who has shown aggression towards staff after visitations or facetime calls from other parties.

Overall, there was not enough evidence to collaborate the allegations listed above.

Based on evidence obtained during the investigation, the two (2) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means 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.

This report was signed by LPA Prieto and Executive Director Tawfik and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2