374604134-6-5-2025-18-AS-APEZ-DHPTK7-20250616144729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604134
Report Date: 06/05/2025
Date Signed: 06/05/2025 02:20:17 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
01/26/2024 and conducted by Evaluator Yolanda Delgado

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240126104012

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: 92	DATE:	06/05/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Diane Domingo, Executive Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Lack of supervision resulted in resident sustaining an injury and hospitalization
Lack of supervision resulted in resident left on the floor for an extended amount of time
Staff did not ensure resident was provided fluids resulting in dehydration
Staff did not give resident's medication as prescribed
Staff did not ensure resident was nourished
Staff did not assist resident with CPAP machine
Resident did not have a call assistance button or a pendant
Staff left resident in wet briefs for an extended period of time resulting in sores
Facility’s screen door was in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Diane Domingo and explained the purpose of the visit.

On January 26, 2024, Community Care Licensing received a complaint alleging lack of supervision resulted in resident sustaining an injury and hospitalization and lack of supervision resulted for staff failing to seek timely medical, Staff did not ensure resident was provided fluids resulting in dehydration, staff did not give resident’s medication as prescribed, staff did not ensure resident was nourished, staff did not assist resident with CPAP machine, resident did have a call assistance button or pendant, staff left resident in wet briefs for an extended period of time resulting in sores, facility’s screen door was in disrepair. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation.
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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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 4

Control Number 18-AS-20240126104012

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: 06/05/2025

NARRATIVE

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(Continued from Page 1)

LPA was able to interview Resident #1 (R1) to obtain pertinent information due to R1’s current cognitive impairment, R1’s interview could not corroborate allegations.

Regarding the allegation lack of supervision that resulted in resident sustaining an injury that caused hospitalization, R1 was found on the floor by staff and was immediately assessed and 911 was called and was taken to the hospital and discharged to a Skilled Nursing Facility for two and half months and returned to Pacifica November 8, 2023.

On December 13, 2023, R1 had a lumbar procedure outpatient and from the procedure was weak in recovery and activities started to decease. R1 was at the facility for seven weeks due to R1’s multiple hospitalization's, procedures and rehabilitations and early removal from the facility.

Regarding the allegation staff did not ensure resident was provided fluids resulting in dehydration, based on staff interviews, staff would provide R1 with water, juice, or smoothies and at times R1 would refuse to drink liquids that were offered, a review of R1’s assessment dated 11/08/2023 stated R1 was independent in feeding self.

Regarding the allegation staff did not give resident’s medication as prescribed, based on staff interviews, R1 was on medication management and staff would take R1’s medication to R1 to take and R1 would refuse to take medications sometimes, staff would give R1 some time and would return with the medication to take, a review of R1’s facility records, an assessment and Physician’s Report revealed R1 needed prompting assistance with medication management.

Regarding the allegation staff did not ensure resident was nourished, based on staff interviews, R1 was prepare meals and sometimes meals were brought to R1 at bedside if R1 did not want to go to the dining area and R1 at times would not eat the food and did not want to be bothered at times, R1 was always provided meals and snacks. A review of facility records, an assessment stated that R1 was able to eat independently.
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SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 18-AS-20240126104012

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: 06/05/2025

NARRATIVE

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(Continued from Page 2)

Regarding the allegation staff did not assist resident with CPAP machine, based on staff interviews, R1 did have a CPAP machine, and staff was aware of R1 having to use CPAP machine at night and at times R1 would refuse assistance from staff with wearing the machine and sometimes would be found during checks not wearing the machine. A review of facilities records for R1, a needs and services plan stated resident uses a CPAP machine at night.

Regarding the allegation resident did not have a call assistance button, based on staff, resident and witnesses interviews it was revealed resident rooms are equipped with emergency call system and pendants are available to residents if they choose. A review of facility records did not reveal on R1’ admission agreement that a pendant was requested or issued to R1.

Regarding the allegation staff left resident in wet briefs for an extended period resulting in sores, based on staff and witnesses interviews, any resident who needs assistance with incontinence care will be check, assessed and changed, it was revealed at times that R1 would not want assistance from staff, R1 would become verbally aggressive with staff, staff would give R1 some time and return to do the assistance with R1’s toileting needs. A review of facility records revealed R1’s assessment stated that R1 needed assistance with toileting and no corroborating documentation of R1 resulting in sores.

Regarding the allegation facility’s screen door was in disrepair, based on staff, residents, and witnesses’ interviews, it was revealed there are sliding glass doors with sliding screen doors that designed to open to 6 inches as a safety precaution for residents in the building. LPA corroborated sliding glass doors and sliding screen doors opening to 6 inches for rooms.

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SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20240126104012

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: 06/05/2025

NARRATIVE

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(Continued from Page 3)

Based on staff interviews, witness interview, facility records, the allegation that Neglect Lack of Care and Supervision for resident’s unwitnessed fall and sustained a fracture that required hospitalization and Neglect Lack of Care and Supervision for staff failing to seek timely medical, Staff did not ensure resident was provided fluids resulting in dehydration, staff did not give resident’s medication as prescribed, staff did not ensure resident was nourished, staff did not assist resident with CPAP machine, resident did have a call assistance button or pendant, staff left resident in wet briefs for an extended period of time resulting in sores, facility’s screen door was in disrepair is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted with Diane Domingo and a copy of this report along with LIC811- Confidential Names list was provided.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

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