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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 02:25:58 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
03/09/2023 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 18-AS-20230309130057
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: 41DATE:
03/30/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Diane DomingoTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility failed to provided a comfortable environment for resident.
INVESTIGATION FINDINGS:
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On 03/20/25, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent unannounced complaint visit to the facility above. LPA met with Executive Director (ED) Diane Domingo and explained the purpose of today's visit.

The investigation consisted of the following: On 03/29/25, at 8:30 am, LPA obtained copies of the resident roster and facility roster. On 03/29/25, between 1:00 pm and 2:00 pm, LPA interviewed five (5) residents #2, (R2-R6), and between 2 00 pm to 3: 30 pm, LPA interviewed six (6) staff, #1-6, (S1-S6), and (ED)Diane Domingo and other pertinent records associated with this complaint. On 03/30/25, at 8:30 am LPA, Richard reviewed and obtained the following documents for resident #1 (R1): Admission Agreement (dated 12/13/22), Physician report (dated 12/16/21), and Needs and Service Plan LIC625 (dated 01/19/21). LPA was unable to interview Resident #1 (R1), as R1 passed away on 04/18/2023.
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-20230309130057
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: The facility failed to provide a comfortable environment for residents.

This complaint alleges the facility had construction occurring above the resident's (R#1s) room and this disturbed the resident.

On 03/29/25, between 1:00 pm and 2:00 pm, LPA Richard interviewed five (5) Residents, #2-6 (R2- R6). LPA found, 5 out of 5 denied the allegations and did not state hearing noises due to construction. The residents did not express issues with the facility being unsafe and an uncomfortable environment. LPA conducted interviews with three (3) residents (R1-R3), and 3 out of 3 stated that while living at the facility, they have not noticed construction occurring.

On 03/29/25, between 2:00 pm and 3:30 pm, LPA interviewed six (6) staff #1-6 (S1- S6). LPA found, 6 out of 6 denied the allegation and stated that the facility is safe and comfortable for residents. On 03/29/25, between 2:00 pm and 3:30 pm, LPA interviewed with Business Director (BD) John McGregory, who stated that there was no construction going on at the facility on 03/09/23. The BD stated the facility was painting room #148, which is located above room #120 (R#1s room). BD #1 stated that there was no excessive noise occurring while the painting was performed in Room #148. Additionally, BD #1 stated he received no concerns placed by residents when the painting was performed in Room #148.

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-20230309130057
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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Based on LPA’s observations, and interviews, LPA did not find sufficient evidence to support the allegation that, facility failed to provide a comfortable environment for residents. Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged allegation is valid or did occur, therefore, the allegation is Unsubstantiated.

No deficiencies were cited. Exit interview conducted. A copy of this report was provided to the 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)
Page: 3 of 3