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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604300
Report Date: 02/20/2025
Date Signed: 02/20/2025 05:13:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20240220215636
FACILITY NAME:PACIFICA SENIOR LIVING OCEANSIDEFACILITY NUMBER:
374604300
ADMINISTRATOR:BANKS, JAQUELINEFACILITY TYPE:
740
ADDRESS:5508 AVENIDA PACIFICA WAYTELEPHONE:
(760) 978-6602
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY:165CENSUS: 101DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Executive Director Kristel JohnsonTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff did not provided food of good quality
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced complaint investigation visit. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Kristel Johnson.
Throughout the investigation, the Department secured records and conducted interviews with several sources including staff and residents.

It was alleged staff did not provide food of good quality. On 02/28/2024, it was reported to the Department the food served at the facility was cold, over cooked, or under cooked.

Interviews with several sources, including staff and residents, confirmed there were occasions when the food was cold, over seasoned, under cooked. or overcooked, making the food inedible. Sources consistently described the food as not fresh, including vegetables, tough to cut with a fork and knife, and not of good quality. One source recalled an instance when food was delivered to the memory care unit and the food was overcooked, therefore, it could not be served to the residents.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 08-AS-20240220215636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE
FACILITY NUMBER: 374604300
VISIT DATE: 02/20/2025
NARRATIVE
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An additional source revealed the food not being of quality was an ongoing issue. This was mentioned to management on several occasions, but the concern persisted. Although there were interviews with several sources that did not disclose any concerns with the quality of food, there was enough evidence to substantiate the allegation. This deficiency was cited in an LIC 9099D form and a plan of correction was jointly formulated with Executive Director Johnson.

An exit interview was conducted with Kristel Johnson, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240220215636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING OCEANSIDE
FACILITY NUMBER: 374604300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2025
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (b) (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement was not met as evidenced by:
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Executive Director agreed to train dining staff on quality of food and submit proof to the LPA by 3/20/2025.

ED agreed to discuss food concern with residents during town hall meeting on 2/26/2025.
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Based on interviews, the licensee did not ensure the food provided to residents was of good quality, which posed a potential health, safety, and personal rights risk to all residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3