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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603451
Report Date: 08/28/2024
Date Signed: 08/28/2024 03:53:56 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
06/14/2021 and conducted by Evaluator Liliana Silveira
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20210614164509
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: 115DATE:
08/28/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Resident Services Director Cherryrose GajoTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident eloped from facility due to lack of supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced complaint investigation visit. LPA Silveira introduced themselves, met with Resident Services Director Cherryrose Gajo and disclosed the purpose of the visit. The purpose of the visit was to deliver complaint findings for the above-mentioned allegation.

The Department’s investigation consisted of interviews with staff and outside sources, as well as a facility records review. On 06/14/21 it was alleged that Resident #1 (R1) eloped from the facility due to lack of supervision. A review of R1’s Physician’s Report dated 05/14/21 revealed that R1 was diagnosed with a major neurocognitive impairment and was not able to leave the facility unassisted. An interview with the Executive Director (ED) on 06/21/21 revealed that R1 had left the facility without staff knowledge. The ED personally searched for R1, found them at a store nearby and brought them back to the facility. (CONTINUED ON LIC 809-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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 3
Control Number 08-AS-20210614164509
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: 08/28/2024
NARRATIVE
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(CONTINUED FROM LIC 809) An interview with an outside source also revealed that R1 eloped from the facility a second time, approximately one week after the first elopement, found by law enforcement, confused and lost in a different city.

Based on interviews and records review, the allegation that a resident eloped from the facility due to lack of supervision was determined to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. Pursuant to the California Code of Regulations, Title 22, Division 6, a deficiency is cited on the attached LIC 9099-D.

An exit interview was conducted and a copy of this report, along with the Licensee Rights (LIC 9058 03/22) were provided to Cherryrose, whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210614164509
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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2024
Section Cited
HSC
1569.312(D)
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HSC 1569.312(d) Basic services requirements: Being aware of the resident's general whereabouts, although the resident may travel independently in the community.

This requirement is not met as evidenced by:
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Resident Services Director will initiate an in-service elopment training will all staff by POC Due Date.
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Based on interviews and record review, the licensee did not ensure supervision was provided to 1 out of 101 residents [R1], which posed a potential health and safety 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: Denise Powell
LICENSING EVALUATOR NAME: Liliana Silveira
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3