374604134-3-30-2025-18-AS-RORN-DFJPUZ-20250408113823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604134
Report Date: 03/30/2025
Date Signed: 03/30/2025 02:17:01 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
10/16/2023 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 18-AS-20231016150752

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: 41	DATE:	03/30/2025
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Diane Domingo		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility does not provide meals in the quantity necessary for resident

INVESTIGATION FINDINGS:

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03/30/2025, at 8:15 am, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent unannounced complaint visit to the facility above. LPA met with the Executive Director, Diane Domingo, and explained the purpose of today's visit.

The investigation consisted of the following: On 03/30/25, LPA obtained copies of the resident roster, staff roster, facility menus (dated January 2025, February 2025, and March 2025), and a copy of the alternative meal menu. On 03/29/25, between 11:00 am and 12:00 pm, LPA Richard toured the kitchen and observed lunch being served. On 03/29/25, between 1:00 pm and 2:00 pm, LPA interviewed five (5) residents #2 (R2- R6). Between 2:00 pm 3 and 30 pm, LPA interviewed six (6) staff, #1-6 (S1-S6), Executive Director Diane Domingo (ED), and other pertinent records associated with this complaint. On 03/30/25, LPA Richard reviewed and obtained copies of the following documents for Resident #1 (R1): Admission Agreement (dated 03/05/2023), Physician Report (dated 05/24/2023), and Needs and Service Plan LIC625 (dated 012/30/22). LPA was unable to interview Resident #1 as R1 no longer resides in this facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
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-20231016150752

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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Allegation: Facility does not provide meals in the quantity necessary for residents.

This complaint alleges that the facility does not provide sufficient portion sizes to residents.

On 03/29/25, between 1:00 pm and 2:00 pm, LPA Richard interviewed five (5) Residents, #2-6 (R2- R6). LPA found, Five out of five denied the allegations and stated that the facility serves good-quality food and ample servings. Five out of five residents stated that they could ask for a second serving if they were not full. The residents stated the facility served them three meals a day and snacks between meals.

On 03/29/25, between 2:00 pm and 3:30 pm, LPA interviewed six (6) staff, #1-6 (S1- S6), and found 6 out of 6 staff stated that the meals served were sufficient portion sizes. Staff interviewed stated that Residents can ask for a second serving of food when requested. Additionally, 6 out of 6 staff members stated that the residents are served high-quality, nutritious meals with various options, and no resident has complained to staff about not being served enough food. On 03/29/25, at 2:00 pm, LPA interviewed the Executive Director (ED)/ Domingo, who denied the allegation and stated that the facility provides sufficient food to residents daily. ED/Domingo states the facility food items are consistently stocked, and food delivery occurs two times per week to ensure food items are replenished.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
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-20231016150752

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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On 03/29/25, between 1:00 pm to 2 pm, LPA Richard reviewed the facility's menu (dated 02/02/25 to 03/29/25), and this revealed the facility had various food options. LPA Richard observed that the facility food supply exceeds a month of perishables and three days of non-perishables in stock. LPA Richard also observed the resident lunch period and found the food served appeared to be ample in portion size.

Based on LPA's observations, interviews, and record reviews, LPA did not find sufficient evidence to support the allegation that the facility does not provide meals in the quantity necessary for residents. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove that it is valid or did occur; therefore, the allegation is Unsubstantiated.

No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to Executive Director Diane Domingo.

SUPERVISORS NAME: Antonine Richard
LICENSING EVALUATOR NAME: Antonine Richard
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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