374603451-4-8-2022-08-AS-JRAE-CDX2AD-20220428171318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603451
Report Date: 04/08/2022
Date Signed: 04/08/2022 04:04:44 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/14/2022 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220214130037

FACILITY NAME:	PACIFICA SENIOR LIVING ESCONDIDO		FACILITY NUMBER:	374603451
ADMINISTRATOR:	AMY BANAGA		FACILITY TYPE:	740
ADDRESS:	1351 E WASHINGTON AVE		TELEPHONE:	(760) 741-3055
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY:	143	CENSUS: 103	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Executive Director Amy Banaga		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff not following infection control masking guidance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong and Interim Assistant Program Administrator (IAPA) Icela Estrada conducted an unannounced subsequent visit, to deliver a finding regarding the above complaint allegation. LPA and IAPA themselves to the receptionist and met with and discussed the purpose of the visit with Executive Director Amy Banaga.

During the investigation, the Department toured the facility, reviewed facility records, outside source records and conducted interviews with staff and the executive director.

On January 18, 2022, LPA and Licensing Program Manager (LPM), John Rante conducted a tour of the facility and observed Staff 1 (S1) wearing a face mask only covering his mouth and Staff 2 (S2) not wearing a face mask. During the visit, LPM discussed the importance of employees wearing face masks while in the facility with the Executive Director. On January 25, 2022, LPA conducted a subsequent visit to the facility and observed S2 without a face mask once again.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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 08-AS-20220214130037

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PACIFICA SENIOR LIVING ESCONDIDO	FACILITY NUMBER: 374603451
	VISIT DATE: 04/08/2022

NARRATIVE

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On February 9, 2022, LPA conducted a subsequent visit to the facility and while touring the facility with the Executive Director, they observed S2 wearing a face mask on her chin. LPA asked S2 why she was not wearing the face mask properly while providing grooming services to residents, S2 advised it was uncomfortable. LPA offered alternatives but S2 declined. LPA asked that she position the face mask properly and S2 complied.

During the period of December 27, 2021 and February 8, 2022, the facility had one or more residents in the facility with active COVID-19 diagnoses. Interviews with outside sources revealed that on multiple occasions staff have been observed without face masks. The outside source stated that the staff exposed residents in care. During the period the outside sources observed staff without face masks, the facility had COVID-19 positive residents.

During today’s visit, LPA and IAPA observed S1 not wearing a mask but minutes later he put one on. A review of staff records revealed S1 was verbally counseled for not wearing face masks properly on July 6, 2020 and received Personal Protective Equipment (PPE) training on August 27, 2020.

Based on staff interviews, review of records, and observations, a preponderance of evidence exists to support the allegation that facility staff are not following infection control masking guidance. The allegation is therefore substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Amy Banaga, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 01/16) were provided via E-mail.

SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220214130037

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PACIFICA SENIOR LIVING ESCONDIDO	FACILITY NUMBER: 374603451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/22/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observations, records reviewed, and interviews, he licensee did not protect the personal rights of residents in care to receive safe and healthful accommodations	1 2 3 4 5 6 7	The Executive Director (ED) indicated that S1 was couseled recently for not wearing a face mask and most likely will be terminated for not following guidance. ED agrees to request PPE training for all staff.
	8 9 10 11 12 13 14	in that S1 and S2 did not wear face masks while in the facility during a COVID-19 outbreak. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: John Rante
LICENSING EVALUATOR NAME: Iby Strong
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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