374603451-9-21-2022-18-AS-RSTS-CV8VX8-20230831164906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603451
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:44:37 PM

Unsubstantiated

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
09/19/2022 and conducted by Evaluator Tricia Danielson

COMPLAINT CONTROL NUMBER: 18-AS-20220919152048

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:	09/21/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Amy Banaga, Executive Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident not allowed visitors.
Staff not responding in timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to initiate an investigation into the allegations listed above. LPA met with Executive Director Amy Banaga and explained the purpose of the visit.
During today's visit, LPA interviewed two(2) staff, one(1) resident, and reviewed facility records. Regarding the allegation "Resident not allowed visitors", it was alleged that on September 11, 2022, a visitor visiting Resident #1(R1) was escorted from the premises at the culmination of their visit and was told they could not return. Records reviewed indicated that the visitor was given entry to the facility for a visit and did visit with R1. Interview with Staff #1(S1) revealed the visitor was in fact escorted from the premises following their visit and informed them they could not return. Facility staff have since learned that they were erronuous in their understanding the reason of preventing the visitor from visiting again however, the visitor has not made any attempts to visit since September 11, 2022. Regarding the allegation "Staff not responding in timely manner", it was alleged that staff often do not assist with providing R1's water cup when it is out of reach. Interview with R1 revealed R1 has not had an instance when their water cup was out of reach requiring staff assistance. Additionally, (CONTINUED ON LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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 18-AS-20220919152048

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
	VISIT DATE: 09/21/2022

NARRATIVE

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(CONTINUED FROM LIC9099)
LPA observed R1 traversing in a wheelchair from the dining room to their room via the hallway without assistance. Upon arrival to their room, LPA observed R1 rise from the wheelchair and climb into their bed unassisted. LPA also observed R1's bottle of water on their side table next to their wheelchair.
Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names List.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC9099 (FAS) - (06/04)

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