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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604478
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:37:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/22/2022 and conducted by Evaluator Dang Nguyen
COMPLAINT CONTROL NUMBER: 08-AS-20220722110605
FACILITY NAME:SOUTH PACIFIC VILLAFACILITY NUMBER:
374604478
ADMINISTRATOR:PRONOVOST, SHANELFACILITY TYPE:
740
ADDRESS:543 GUIDERO WAYTELEPHONE:
(916) 768-6948
CITY:ENCINITASSTATE: CAZIP CODE:
92024
CAPACITY:6CENSUS: 6DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver Alfred RiosaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee retaliated against a resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alfred Riosa.

The Complainant alleged that Licensee retaliated against a resident, after CCLD had commenced investigating a separate Complaint which preceded this one. CCLD’s investigation involved an unannounced facility tour / welfare check, review of relevant third-party records, and interviews of pertinent facility staff and outside sources.

Under regulations, residents of privately-operated RCFE’s have the right to be free from “interference, coercion, discrimination, and retaliation in exercising their rights,” rights of which include “confidentially registering complaints” with the Department. [CONTINUED ON LIC 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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-20220722110605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SOUTH PACIFIC VILLA
FACILITY NUMBER: 374604478
VISIT DATE: 04/25/2024
NARRATIVE
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[CONTINUED FROM LIC 9099]

On 07/07/2022, CCLD commenced a separate complaint investigation regarding this facility, not disclosing the identity of that case’s Complainant. During that site visit, Licensee was instructed verbally and in writing that the case status as of that date was “Needs Further Investigation,” that the investigation was active/ongoing, and that additional interviews would need to be conducted by CCLD.

Interviews of outside sources and review of outside source records showed: After CCLD’s departure from the facility on 07/07/2022, Licensee approached and questioned responsible parties and hospice personnel belonging to two residents [R1 and Resident #2 (R2)] regarding the complaint allegations, allegations of which were still under active investigation by the Department. Persons reported that Licensee’s actions created discomfort.

Based on interviews and records, a preponderance of evidence exists to show that Licensee’s actions did not uphold residents’ right to confidentially register complaints, free from interference and/or retaliation. The allegation is therefore Substantiated. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee.

An exit interview was conducted with Riosa, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20220722110605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SOUTH PACIFIC VILLA
FACILITY NUMBER: 374604478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2024
Section Cited
CCR
87468.2(a)(3)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents…shall have all of the following personal rights: (3)…Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.” This requirement was not met, as evidenced by:
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Licensee agreed to utilize a third-party source to retrain all facility managers and staff on Resident’s Personal Rights, as articulated in CCLD’s form LIC613C-2. Licensee agreed to submit the training sign-in sheet to LPA, by the POC due date.
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Based on records and interview, Licensee did not ensure that 2 of 6 residents (R1 and R2) were free from interference and retaliation in exercising their rights. This posed a potential personal rights risk to persons 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: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3