374603451-9-21-2022-18-AS-DMUN-CL22YD-20221109164831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603451
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:54:33 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
07/05/2022 and conducted by Evaluator Tricia Danielson

COMPLAINT CONTROL NUMBER: 18-AS-20220705163733

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:	01:45 PM
MET WITH:	Amy Banaga, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not wearing masks
Resident has bed bugs
Staff did not properly administer resident's medications

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude 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 reviewed and obtained copies of facility maintenence records and interviewed five(5) staff. Regarding the allegation "Staff are not wearing masks", it was alleged that on June 30, 2022, four(4) staff were observed to not be wearing a mask as required and that their director was aware of this issue and did not address it. Four(4) of four(4) staff and one(1) of one(1) residents interviewed did not corroborate the allegation and records reviewed indicated that one of the staff accused was not working on that day. Regarding the allegation "Resident has bed bugs", it was alleged that Resident #1(R1) has bed bugs. Interviews conducted and records reviewed revealed the facility has had incidents of bed bugs occassionally in recent years. The facility has maintained a contract with an extermination company to assist them when incidents do occur and Community Care Licensing has been made aware of this issue. During today's visit, LPA observed heat treatments being applied to various areas of concern in the facility. Although the facility is experiencing a bed bug incident, they are taking appropriate steps to help mitigate the issue. (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-20220705163733

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)
Regarding the allegation "Staff did not properly administer resident's medication", it was alleged that Staff #1(S1) administered medication and water to R1 while R1 was lying completely flat. Interview with S1 did not corroborate this allegation nor did interview with R1.

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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