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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 01/30/2025
Date Signed: 01/30/2025 11:19:20 AM

Unfounded


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
05/24/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210524094053
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: 75DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Executive Director Eva TawfikTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staffs do not seek timely medical care.
INVESTIGATION FINDINGS:
1
2
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5
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7
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9
10
11
12
13
On 01/30/2025 at 10:15 AM, Licensing Program Analyst (LPA), Melody Brown, visited the facility to deliver the investigative findings for the above allegation. LPA Brown identified herself and discussed the purpose of the visit with Executive Director (ED) Eva Tawfik.

The investigation of the allegation was conducted by Department staff. The investigation consisted of file review and interviews with relevant parties. The allegation indicates staff do not seek timely medical care. During the Department staff investigation, it was indicated that Resident #1 (R1) had a witnessed fall on 05/07/2021 at approximately 09:00 PM and it was reported that R1 used R1's right hand for balance and R1 complained of hand and wrist pain. In addition, Department staff investigation revealed that the facility contacted R1's Healthcare provider the same day. Moreover, records review indicated that R1's Healthcare provider completed a visit at the facility with R1 on 05/11/2021 and the results were received the same day and were shared with R1's primary physician where a referral was made to an Orthopedic with a first available appointment on 05/18/2021. ***Continuation in LIC9099C***
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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-20210524094053
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: 01/30/2025
NARRATIVE
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Furthermore, Department staff noted that R1 was seen by the Orthopedic doctor on 05/18/2021 and was placed in a short-arm cast. In addition, Department staff reviewed the facility's Narrative Charting and it indicated that on 05/23/2021, R1 removed the cast and notification was made to R1's doctor and R1 was sent to the Emergency Room to have R1's wrist splinted. Also, Department staff noted that a new appointment with the Orthopedic was scheduled and completed on 06/01/2021. Lastly, Department staff obtained additional verification and documentation through R1's Healthcare provider, R1's primary physician and the Orthopedic doctor.

This agency has investigated the complaint alleging staffs do not seek timely medical care. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Executive Director Eva Tawfik and a copy of this report (LIC9099) was discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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
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
05/24/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210524094053

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: 75DATE:
01/30/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Executive Director Eva TawfikTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility residents and staff have scabies.
Responsible parties of residents are not contacted regarding incidents.
Staffs are told not to share information about the resident with the families.
Staff is not giving medications per the doctors order.
Food service inadequate.
Staff is crushing medications without a doctor's order.
PPE is not provided.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/30/2025 at 10:15 AM, Licensing Program Analyst (LPA), Melody Brown, visited the facility to deliver the investigative findings for the above allegation. LPA Brown identified herself and discussed the purpose of the visit with Executive Director (ED) Eva Tawfik.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observation, review of records and interviews with relevant parties. The first allegation indicates that facility residents and staff have scabies. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that they do not have scabies and did not observe a staff or resident with scabies. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Five (5) of five (5) staffs interviewed indicated that there's no incident that residents and staffs have scabies at the facility. During the facility visit on 01/24/2025 and 01/29/2025, LPA Brown did not observe a staff or resident with scabies. ***Continuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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-20210524094053
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: 01/30/2025
NARRATIVE
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The second allegation indicates that responsible parties of residents are not contacted regarding incidents. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that staffs are contacting their family or responsible party regarding the incidents at the facility. Three (3) of three (3) residents interviewed stated that staffs at the facility are communicating regularly with their family and responsible party and they could not remember an incident at the facility that staffs are not reporting incidents to their family or responsible party. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Five (5) of five (5) staffs interviewed indicated that they are reporting all incidents at the facility to a resident family or responsible party the same day it happened. Five (5) of five (5) staffs interviewed stated that all staff at the facility were provided training to report all incidents at the facility to residents family or responsible party and it's the management that report incidents to Community Care Licensing Division (CCLD) and other government agencies if applicable. Interviews with five (5) of five staffs revealed that there's no incident that happened at the facility that a staff did not contact a resident family or responsible party regarding incidents at the facility.

The third allegation indicates that staffs are told not to share information about the resident with the families. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interview with three (3) of three (3) residents indicated that staffs at the facility are sharing all information about them to their family or responsible party. Three (3) of three (3) residents interviewed stated that they do not know of an incident at the facility that staffs were told not to share information about them to their family or responsible party. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Five (5) of five (5) staffs interviewed indicated that they were not told by the management not to share information about their residents to their family or responsible party. Interviews with five (5) of five (5) staffs revealed that all staffs are sharing information about a resident to their family or responsible party to keep them updated.

The fourth allegation indicates that staff is not giving medications per the doctors order. Interviews with three (3) of three (3) residents indicated that staffs at the facility are giving their medications daily per their doctor's order. Three (3) of three (3) residents interviewed reported that staffs at the facility never missed giving their medications per their doctor's order. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping and three (3) residents were not oriented. Five (5) of five (5) staffs interviewed indicated that they are giving their residents medications per their residents' doctors order. ***Cont. in LIC9099***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20210524094053
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: 01/30/2025
NARRATIVE
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Interviews with five (5) of five (5) staffs revealed that they are using electronic medication administration record (MAR) to ensure that they are giving their residents medications per their doctors order. During the facility visit on 01/24/2025 and 01/29/2025, LPA Brown audited five (5) residents medications and LPA Brown observed that residents medications were given per their doctors order.

The fifth allegation indicates that food service inadequate. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that they like the food at the facility and staffs are always serving them good portion of food and they can get second serving if they prefer. Three (3) of three (3) residents interviewed reported that the facility staffs are always serving them breakfast, morning snacks, lunch, afternoon snacks, and dinner, and no incident happened at the facility that food service was inadequate. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Interview with five (5) of five (5) staffs indicated that they are serving all their residents healthy and enough amount of food and there's no incident that happened at the facility that their food service is inadequate. During the facility visit on 01/24/2025, ED Tawfic provided LPA Brown the facility Menu. Moreover, LPA Brown conducted a quick tour of the facility and observed that the facility has more than the required two (2) days' supply of perishable food and more than seven (7) days supply of non-perishable food.

The sixth allegation indicates that staff is crushing medications without a doctor's order. Interviews with three (3) of three (3) residents indicated that there's no incident at the facility that staffs are crushing their medications without their doctor's order. LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Five (5) of five (5) staffs interviewed reported that they are not crushing their residents medication without a doctor's order. Interview with five (5) of five (5) staffs indicated that there's no incident that happened at the facility that a staff is crushing residents' medications without a doctor's order. Five (5) of five (5) staffs interviewed revealed that medication training was provided to medical technician (MedTech) staffs, and they never crushed residents medications without a doctor's order. During the facility visit on 01/24/2025 and 01/29/2025, LPA Brown observed that MedTech staffs are not crushing a resident medication without a doctor's order.

The seventh allegation indicates that PPE is not provided. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with three (3) of three (3) residents indicated that staffs at the facility are wearing gloves and mask when they are assisting them. **Cont. in LIC9099C*
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20210524094053
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: 01/30/2025
NARRATIVE
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 LPA Brown unable to interview five (5) residents as two (2) residents were sleeping, and three (3) residents were not oriented. Interviews with five (5) of five (5) staffs indicated that they are always provided personal protective equipment (PPE) at the facility. Five (5) of five (5) staffs interviewed stated that they have plenty of PPE supplies on all six (6) cottages at the facility and they never ran out of PPE supplies. Interview with five (5) of five (5) staffs revealed that the PPE supplies are always available to them on each cottage. During the facility visit on 01/24/2025, LPA Brown noted that the facility has sufficient PPE supplies maintained per cottages.

Based on the evidence, the allegation that facility residents and staff have scabies (Allegation #1), responsible parties of residents are not contacted regarding incidents (Allegation #2), staffs are told not to share information about the resident with the families (Allegation #3), staff is not giving medications per the doctors order (Allegation #4), food service inadequate (Allegation #5), staff is crushing medications without a doctor's order (Allegation #6), PPE is not provided (Allegation #7) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.


An exit interview was conducted where this report, LIC9099 was discussed and provided to ED Eva Tawfik
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6