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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603451
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:34:35 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, 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
07/25/2022 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20220725094743
FACILITY NAME:PACIFICA SENIOR LIVING ESCONDIDOFACILITY NUMBER:
374603451
ADMINISTRATOR:AMY BANAGAFACILITY TYPE:
740
ADDRESS:1351 E WASHINGTON AVETELEPHONE:
(760) 741-3055
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:143CENSUS: 101DATE:
08/02/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Amy Banaga, Executive DirectorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff refused to accept resident back into the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegation listed above. LPA met with Executive Director (ED) Amy Banaga and explained the purpose of the visit.
During today's visit, LPA interviewed ED Banaga and discussed the events surrounding Resident #1 (R1) and their recent hospitalization. Regarding the allegation "Staff refused to accept resident back into the facility", it was alleged that R1 was not permitted to return to the facility upon their discharge from the hospital on July 21, 2022 due to safety reasons. Interview with ED Banaga revealed she had received a phone call from R1's hospice agency to discuss R1's return to the facility and did inform the hospice agency that the facility would not accept R1 back due to the safety risk involved in accepting R1 back. Based on LPA interview which was conducted, the preponderance of evidence standard has been met, therefore the allegation "Staff refused to accept resident back into the facility" is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview as conducted with ED Banaga and a copy of this report was provided along with Appeal Rights and LIC811- Confidential Names List.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
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 18-AS-20220725094743
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
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING ESCONDIDO
FACILITY NUMBER: 374603451
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
87468.2(a)(20)
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Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1... residents in privately operated care...facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions. A license shall comply with all
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Licensee states they will submit a written statement of understanding on the regulation cited by POC due date of 8/12/2022.
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eviction and relocation protections for residents. This requirement was not met as evicdenced by: the licensee did not refrain from involuntarily evicting R1. Based on LPA interview conducted, the licensee refused to accept R1 upon their discharge from the hospital. This poses a potential health, safety and personal rights risk to residents in care.
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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: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2