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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604134
Report Date: 03/30/2025
Date Signed: 03/30/2025 12:04:58 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
07/27/2023 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 18-AS-20230727083953
FACILITY NAME:PACIFICA SENIOR LIVING VISTAFACILITY NUMBER:
374604134
ADMINISTRATOR:ENCISO, KARENFACILITY TYPE:
740
ADDRESS:760 EAST BOBIER DRIVETELEPHONE:
(760) 941-1480
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:172CENSUS: 86DATE:
03/30/2025
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Executive Director Diane DomingoTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff yelled at another staff member in the presence of multiple residents.
Staff made residents feel uncomfortable.
INVESTIGATION FINDINGS:
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On 03/30/25 at 8:15 am Licensing Program Analyst (LPA) Villegas conducted a subsequent 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, and requested the following documents for resident #1 (R1): emergency ID form, physicians report dated: 4/6/23, physicians orders dated:8/15/23, PRN authorization letter dated: 8/22/23, preplacement appraisal dated: 11/8/22, needs and service plan dated: 12/7/23, resident assessment dated: 12/7/23, medication refusal notifications dated: 7/3/23, 7/9/23, 7/20/23, 7/30/23, 8/7/23, and documentation on increase/transfer/level of care dated 6/5/23. on 3/25/25 LPA conducted phone interview with R1, on 03/29/25 from 1pm-3pm LPA conducted Interviews with staff #1-7 (S1-S7), and between 3pm- 3:25pm LPA conducted interviews with resident # 2-5 (R2-R5). On 03/30/25 LPA obtain a copy of the staff roster.
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 2
Control Number 18-AS-20230727083953
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: Staff yelled at another staff member in the presence of multiple residents.
It is being alleged that former Executive Director yelled at a staff in the presence of 2 residents in care.
On 03/29/25 from 1pm-3pm LPA conducted Interviews with S1-S7, 6 of 7 staff interviewed denied the allegation above, 1 of 7 staff interviewed confirmed the allegation above and reported that 2 staff members were arguing by the dinning room, and nothing was done to diffuse. On 3/25/25 and 03/29/25 LPA conducted interviews with R1-R5 regarding the allegation above, 4 of 5 residents interviewed denied the allegation above, 1 of 5 residents interviewed reported resident did not observe the allegation above, but the information was disclosed by peers.

Allegation: Staff made residents feel uncomfortable.

It is being alleged that residents felt uncomfortable due to staff yelling.
On 03/29/25 from 1pm-3pm LPA conducted Interviews with S1-S7, 7 of 7 staff interviewed denied the allegation above and reported treating all residents in care with respect and dignity. On 3/25/25 and 03/29/25 LPA conducted interviews with R1-R5 regarding the allegation above, 4 of 5 residents interviewed denied the allegation above and reported feeling safe around staff, 1 of 5 residents interviewed confirmed the allegation above and reported feeling uncomfortable as resident was yelled at by a facility staff.

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)
Page: 2 of 2