374604134-3-30-2025-18-AS-RORN-DFBT7N-20250401142902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604134
Report Date: 03/30/2025
Date Signed: 03/30/2025 12:03:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
03/27/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 18-AS-20240327103809

FACILITY NAME:	PACIFICA SENIOR LIVING VISTA		FACILITY NUMBER:	374604134
ADMINISTRATOR:	ENCISO, KAREN		FACILITY TYPE:	740
ADDRESS:	760 EAST BOBIER DRIVE		TELEPHONE:	(760) 941-1480
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	172	CENSUS: 86	DATE:	03/30/2025
		UNANNOUNCED	TIME BEGAN:	08:18 AM
MET WITH:	Executive Director Diane Domingo		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility does not have sufficient staff to meet the care needs of residents.
Staff does not ensure facility has sufficient quantity of food for residents in care.
Staff do not ensure proper sanitary practices are followed while providing bathing services to residents in care.

INVESTIGATION FINDINGS:

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On 03/30/25 at 8:10 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director Diane Domingo as the purpose of today’s visit was explained.

The investigation consisted of the following: On 03/29/25 LPA Villegas obtained copies of the resident roster, list of residents that require bed baths, facility menus dated January 2025, February 2025, and March 2025, alternative menu, and requested copies of the following documents for resident #1 (R1) emergency ID form, physicians report dated: 10/3/23, physicians orders dated: 8/15/23, PRN authorization form dated 8/23/23, needs and service plan dated: 4/14/23. On 03/29/25 LPA conducted a tour of the facility kitchen and observed the lunch service from 11:15am- 12pm. On 03/29/25 between 1pm-3pm LPA conducted Interviews with staff #1-7 (S1-S7), and between 3pm-3:25pm LPA conducted interviews with resident# 1-5 (R1-5). On 03/29/25 LPA conducted a file review for R1s file. On 03/30/25 LPA obtain a copy of the staff roster, transportation schedule, appointment book, hospice notes, and facilities driver file.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2025

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 18-AS-20240327103809

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING VISTA	FACILITY NUMBER: 374604134
	VISIT DATE: 03/30/2025

NARRATIVE

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The investigation revealed the following:
Allegation: Facility does not have sufficient staff to meet the care needs of residents.

It is being alleged that facility does not have sufficient staff to operate the facility transport vehicle. On 03/29/25 between 1pm-3pm LPA conducted Interviews with S1-S7 regarding the allegation above, 5 of 7 staff interviewed denied the allegation above, 2 of 7 staff interviewed reported being unaware of transportation procedures or schedules. On 03/29/25 between 3pm-3:25pm LPA conducted interviews with resident R1-R5, 4 of 5 residents interviewed denied the allegation above, 1 of 5 residents interviewed confirmed the allegation above and stated resident has been unable to obtain the care needed due to transportation. On 03/30/25 LPA conducted a review of LIC 500 dated 03/18/25, LPA observe facility driver to be scheduled 5 days a week from 8:30am-5pm. On 03/30/25 LPA conducted a review of appointment calendar and appointment book, LPA observed R1 to be scheduled for transportation between 2-4 times a month.

Allegation: Staff does not ensure facility has sufficient quantity of food for residents in care.

It is being alleged that the facility has ran out of food 3 times during dinner service. On 03/29/25 LPA conducted a tour of the facility kitchen and observed the dry pantry, refrigerator, and freezer to be fully stocked and labeled with expiration dates. On 03/29/25 during kitchen tour LPA also observed food delivery taking place. On 03/29/25 between 1pm-3pm LPA conducted Interviews with S1-S7 regarding the allegation above, 7 of 7 staff interviewed denied the allegation above and reported residents can obtain additional food upon request, 2 of 7 staff interviewed also added that the kitchen receives food deliveries 2 times per week. On 03/29/25 between 3pm-3:25pm LPA conducted interviews with resident R1-R5, 4 of 5 residents interviewed denied the allegation above, 1 of 5 residents interviewed confirmed the allegation above and stated resident has gone 3 days without obtaining food. On 03/29/25 LPA conducted a review of R1's narrative charting dated February 2024-March 2024 that R1 refuses meal service completely or resident consumes very little to no food from tray.

Allegation: Staff do not ensure proper sanitary practices are followed while providing bathing services to residents in care.

It is being alleged that residents who require bathing assistance in their bed get their face washed using the same water that was used in the bowl for the rest of their body. On 03/29/25 between 1pm-3pm LPA

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20240327103809

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING VISTA	FACILITY NUMBER: 374604134
	VISIT DATE: 03/30/2025

NARRATIVE

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conducted Interviews with S1-S7 regarding the allegation, 5 of 7 staff interviewed denied the allegation above and reported bed baths are conducted by hospice nurses, 2 of 7 staff interviewed reporting having no knowledge of bathing procedures. On 03/29/25 between 3pm-3:25pm LPA conducted interviews with resident R1-R5 regarding the allegation above, 4 of 5 residents interviewed denied the allegation above and reported not needing shower assistance and having no concerns with the water used for hygiene purposes. 1 of 5 residents interviewed confirmed the allegation above and reported not having a shower for over 3 days. On 03/30/25 LPA conducted a review of hospice notes from October 2024- March 2025 for R1, LPA observed documentation reporting R1 has received 2-3 bed bathes from hospice nurse upon agreement as it is also documented that R1 has refused hospice nurse assistance.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2025

LIC9099 (FAS) - (06/04)

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