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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604300
Report Date: 02/27/2025
Date Signed: 02/27/2025 11:38:02 AM

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
04/24/2024 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20240424134234
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: 110DATE:
02/27/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Executive Director Kristel JohnsonTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff did not ensure that residents rooms were kept clean
Staff did not ensure that residents rooms were kept free from odors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Kristel Johnson.

The Department’s investigation consisted of interviews with residents, staff and outside sources, records review, and a tour of the facility. It was alleged that staff did not ensure that residents rooms were kept clean and that staff did not ensure that residents rooms were kept free from odors.

Interviews with residents and staff and review of the admission agreement revealed that the facility provided weekly housekeeping services which included vacuuming, dusting, cleaning the bathroom, changing linens, and disposing of trash.

Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
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-20240424134234
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: 02/27/2025
NARRATIVE
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Interviews with residents, including Resident 1 (R1) and facility management revealed that in April and May of 2024, the facility experienced a shortage of housekeeping staff resulting in housekeeping services being missed, with at least one resident experiencing two weeks between services. [Executive Director was provided with an LIC811 Confidential Names List to identify R1] According to residents, the facility did not provide any written or verbal communication regarding the housekeeping staff shortage. Interviews with the facility management confirmed that there was difficulty with hiring and maintaining housekeeping staff and during the months of April and May of 2024, the facility only had one full time housekeeper and the housekeeping supervisor was on restricted work duty. Those interviews with facility management also stated that maintenance staff were assisting housekeepers to clean resident rooms, which residents confirmed during interviews. Interviews with housekeeping staff revealed that when fully staffed, two housekeepers were assigned to split the facility’s four two-story buildings in assisted living, and one housekeeper was assigned to the memory care building. Staff estimated that a common daily workload was to clean approximately 5 to 10 resident rooms a day, which included: sweeping, mopping, vacuuming, dusting, taking out the trash, and general cleaning of the apartment’s living area, bathroom, and kitchenette. While housekeepers denied any difficulties with meeting the workload, all housekeepers interviewed by the Department were hired after April 2024 and the alleged timeline of the allegations. Residents stated in interviews that during April and May 2024, the housekeeping services that were provided often did not include all promised tasks, or the service was rushed. Interviews with R1 and housekeeping staff revealed that R1’s room would frequently contain items on the floor such as food wrappers, crumbs, and other clutter. Interviews with R1 and staff revealed that R1 used incontinence briefs and disposed of them in the trash in R1’s bathroom. Additionally, R1, housekeeping staff, and outside sources confirmed that during April and May 2024, soiled incontinence briefs caused R1’s room to smell strongly of urine. Review of the admissions agreement revealed that the facility also offered additional housekeeping services for a fee, and review of R1’s admission agreement addendum signed in 2019 revealed that R1 agreed to pay for an additional day of housekeeping services, totaling two housekeeping services a week.

The Department has investigated the above-mentioned allegations and based on interviews, the preponderance of the evidence has been met, therefore, these allegations are deemed substantiated and noted on the attached LIC9099-D page.

An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20240424134234
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: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers... as necessary to perform... house cleaning...
This requirement has not been met as evidenced by:
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Executive Director stated that the facility is currently fully staffed for housekeeping staff. Executive Director stated that she will provide an inservice training for housekeeping staff on proper cleaning procedures and speak to the housekeeping supervisor.
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Based on interviews, the licensee did not comply with the section cited above in that there were not enough housekeeping staff employed to provide weekly housekeeping services per the admission agreement. This poses a potential personal rights risk to 110 of 110 residents in care.
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Executive Director will provide a copy of the staff sign in sheets for the inservice training to the Department by POC due date of 3/28/2025.
Type B
03/28/2025
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) ... the licensee shall be responsible for the following: (3) Ensuring that... the facility remains free from odors from incontinence. This requirement has not been met as evidenced by:
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Executive Director will speak with R1 to adjust standby assistance days to increase R1's trash disposal to 4 times a week.
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Based on interviews, the licensee did not comply with the section cited above in that resident apartments smelled of urine due to soiled incontience briefs. This poses a potential personal rights risk to 110 of 110 residents in care.
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Executive Director will be providing inservice training for caregivers to check and dispose of trash during any care services. Executive Director will provide sign in sheet for inservice training to Department by POC due date of 3/28/2025.
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: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
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