336425840-4-4-2025-56-AS-KCLS-DFHVS6-20250407164057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 02/28/2025
Date Signed: 04/04/2025 03:06:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO 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
06/07/2023 and conducted by Evaluator Eldin Serrano

COMPLAINT CONTROL NUMBER: 56-AS-20230607172908

FACILITY NAME:	PACIFICA SENIOR LIVING RIVERSIDE		FACILITY NUMBER:	336425840
ADMINISTRATOR:	EVA TAWFIK		FACILITY TYPE:	740
ADDRESS:	6280 CLAY STREET		TELEPHONE:	(951) 360-1616
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	110	CENSUS: 77	DATE:	02/28/2025
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Eva Tawfik, Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility did not administer medication as prescribed.
Facility did not prevent resident from becoming malnourished while in care
Facility did not meet resident’s hygiene needs.
Facility did not prevent resident from developing a pressure injury while in care.
Resident's health declined while in the care of the facility

INVESTIGATION FINDINGS:

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*****This is an amendment *******

On 4/4/2025 at 1:00 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to deliver the findings of the above allegations. LPA Serrano explained the purpose of the visit to the Executive Director Eva Tawfik. The investigation consisted of file review, interviews with staffs and residents as well as observation.

The investigation was conducted by LPA Serrano. The allegations indicate:

#1 Facility did not administer medication as prescribed. – Based on record review, the electronic medication administration record (EMAR) showed the medication was given as prescribed by the physician.

*** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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 56-AS-20230607172908

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 02/28/2025

NARRATIVE

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#2 Facility did not prevent resident from becoming malnourished while in care - Based on interview, observation, and record review, investigation found that (R8) had a daily assignment that showed meals and snacks are being provided by the facility. Information received during investigation did not corroborate that R8 was malnourished because of facility staff neglect.

#3 Facility did not meet resident’s hygiene needs. - Based on interview and file review, the facility has the Daily Assignment for (R8) that showed shower and laundry schedule. Also, information received indicated that R8 was receiving additional services from an outside source from at least 1/20/2023 through 6/6/2023. These services included showers. Information received during investigation did not corroborate that R8s hygiene needs were not being met.

#4 Facility did not prevent resident from developing a pressure injury while in care. - Based on record review (R8) was receiving care from outside services from at least 1/20/2023 through 6/6/2023. Services included care for pressure injury. Information received during investigation did not corroborate facility staff neglect resulting in R8 sustaining a pressure injury.

#5 Resident's health declined while in the care of the facility. - Based on record review, investigation revealed that (R8) was receiving hospice services from at least 1/20/2023 through 6/6/2023. A review of information received during the course of investigation could not corroborate that R8 health condition declined as a result of facility staff neglect.

During the investigation, LPA did not find evidence to corroborate the allegations.

Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means 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, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099, LIC909C were discussed and provided to Executive Director Eva Tawfik.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC9099 (FAS) - (06/04)

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