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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604300
Report Date: 03/09/2026
Date Signed: 03/09/2026 03:50:55 PM

Unsubstantiated


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
07/13/2021 and conducted by Evaluator Rebecca A Borunda
COMPLAINT CONTROL NUMBER: 08-AS-20210713163713
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: 92DATE:
03/09/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Business Office Manager Virgina RodriguezTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff failed to supervise resident resulting in injury
Insufficient staffing to meet resident care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced complaint visit to conduct follow up and deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Business Office Manager Virginia Rodriguez.

During today’s visit, LPA observed residents in care, obtained copies of facility records, and interviewed staff.

The Department’s investigation consisted of interviews with staff and outside sources, records review, and a tour of the facility. It was alleged that staff failed to supervise resident resulting in injury and insufficient staffing to meet resident care needs.

Continued on LIC9099-C page...
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
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 2
Control Number 08-AS-20210713163713
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: 03/09/2026
NARRATIVE
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Review of Resident 1’s (R1’s) medical and care assessment records dated 2021 revealed that R1 had mild cognitive impairment, was confused and disoriented, and required assistance with bathing, grooming, dressing, toileting and multiple safety checks per shift. While assessment records noted that R1 was not a fall risk, review of progress notes for R1 in 2021 revealed that R1 had multiple falls a month, usually with no injuries. Each time R1 fell, staff would assess R1 for any pain or injuries. Review of progress notes for R1 in 2021 revealed that in July 2021, R1 was found on the floor in a common area by staff and was observed to have minor injuries to the head and leg, and R1 complained of pain. Staff called 911 and emergency personnel assessed and transported R1 to the hospital. The Department was unable to obtain copies of R1’s discharge paperwork resulting in the Department’s inability to determine the severity of R1’s injuries. R1’s progress notes showed a pattern of staff conducting regular safety checks on R1, as well as encouraging R1 to attend communal meals and activities.

Review of progress notes for residents revealed that an outside source complained that one staff working in the facility’s memory care was not sufficient to supervise residents overnight. Review of regulations regarding overnight supervision requirements for facilities caring for up to 100 residents revealed that at least one awake staff member was required to be on site with another staff on call and available to respond within 10 minutes. The Department was unable to interview any relevant staff that were working in 2021 or obtain staff schedules in 2021 to determine the staffing level in the facility’s memory care in 2021. However, interviews with staff responsible for oversight of the memory care in 2022 through 2024 revealed that the memory care was staffed with a minimum of 3 care staff during the morning and afternoon shifts, and a minimum of 2 care staff during the overnight shift. Those staff also stated that if a caregiver called out for a shift, other caregivers would be contacted to cover the shift, or the Memory Care Director would provide direct resident care.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22).
SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Rebecca A Borunda
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2026
LIC9099 (FAS) - (06/04)
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