336425840-4-4-2025-56-AS-KCLS-DFHVXH-20250407164934

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 02/28/2025
Date Signed: 04/04/2025 03:33:04 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
10/31/2023 and conducted by Evaluator Eldin Serrano

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20231031151000

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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Staff failed to asssist resident with getting out of bed
Staff failed to meet resident's nutritional needs
Staff failed to meet resident's hygiene needs
Staff member made resident feel uncomfortable

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 allegation. LPA Serrano explained the purpose of the visit to Excutive 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 Staff failed to assist resident with getting out of bed– Based on record review of the facility Daily Assignment record, it was recorded that the resident’s needs and services plan was followed by the facility.

*** 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-20231031151000

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 Staff failed to meet resident's nutritional needs - Based on record review, the facility has 5-week alternating menu with various foods being served. Resident #8 (R8) has a Daily Assignment that showed meals and snacks as being provided. Furthermore, the facility did an assessment because R8 eating habits had changed. Information received during investigation did not corroborate that staff neglected R8’s nutritional needs.

#3 Staff failed to meet resident's hygiene needs - Based on interview and file review, the facility has the Daily Assignment that showed shower and laundry schedule for resident #8 (R8). Information received during investigation did not corroborate that staff neglected R8’s hygiene needs.

#4 Staff member made resident feel uncomfortable - Based on information, LPA is unable to interview resident #8 (R8) to corroborate the allegation due to R8 being deceased. Information received during investigation did not corroborate that R8’s personal rights were violated.

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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