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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604478
Report Date: 02/21/2026
Date Signed: 03/03/2026 08:22:03 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
02/24/2025 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 08-AS-20250224152208
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: 3DATE:
02/21/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Facility staff, Angelina Escobar TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Neglect resulted in stage 4 pressure injury
Lack of incontinence care resulted in skin condition
Medication was not issued as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with facility staff Angelina Escobar and explained the purpose of today's visit.

Regarding the allegation neglect resulted in stage 4 pressure injury. The investigation revealed sufficient evidence to support the allegation. During the investigation, hospice documentation and photos dated 01/21/25 through 02/25/25 showed that Resident #1’s coccyx wound deteriorated from minor skin breakdown to a tunneling stage 4 pressure injury. The resident was identified as high risk for skin breakdown and required repositioning every two hours per hospice and physician orders. Hospice staff consistently documented that Resident #1 was found heavily soiled with urine and feces on multiple visits, with bedding saturated up to the resident’s shoulders. Staff interviews were inconsistent; one caregiver stated the resident was not repositioned during the night “because he was asleep,” while hospice nurses indicated they repeatedly educated staff on proper repositioning and moisture management. Based on the information obtained through interviews, record review, and hospice documentation, the preponderance of evidence revealed the facility failed to provide adequate care and supervision, resulting in a preventable decline in the resident’s skin integrity. Therefore, the allegation is SUBSTANTIATED.
Continued....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
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 5
Control Number 08-AS-20250224152208
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: SOUTH PACIFIC VILLA
FACILITY NUMBER: 374604478
VISIT DATE: 02/21/2026
NARRATIVE
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Regarding the allegation that lack of incontinence care resulted in a skin condition for Resident #1, the investigation revealed sufficient evidence to support the allegation. According to hospice progress notes and interviews, Resident #1 was frequently observed saturated with urine and feces, including bedding and clothing, upon hospice arrival. Staff reported providing incontinence care every three hours and as needed; however, hospice documentation indicated that such care was not consistently provided per the care plan. Hospice staff documented repeated education to facility caregivers on the importance of incontinence checks and timely care. Despite this, there was no record of compliance monitoring or corrective documentation by the facility to ensure staff followed the plan of care. Based on hospice records, interviews, and facility documentation, the preponderance of evidence demonstrates that the facility failed to provide consistent incontinence care, which contributed to further skin deterioration and discomfort. Therefore, the allegation is SUBSTANTIATED.

Regarding the allegation that medication was not issued as prescribed, the investigation revealed sufficient evidence to support the allegation. During the 10-day visit conducted on 02/26/2025, two medication pills were observed on the floor next to Resident #1’s bed. Hospice nursing staff also reported missing Morphine tablets that were not documented on the MAR, and confirmed that staff had been educated multiple times on controlled-substance tracking. A caregiver stated that medications were occasionally crushed in ice cream to assist the resident with swallowing. Review of the physician’s report and medication orders revealed no authorization for crushing any medication. Based on observations, interviews, and record review, the preponderance of evidence demonstrated that the facility failed to ensure medications were administered and documented according to physician directions and hospice protocol. Therefore, the allegation is SUBSTANTIATED.

The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and the California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on H&S Code section 1569.49(f). Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted with Facility staff, Angelina Escobar , and appeal rights provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/24/2025 and conducted by Evaluator Sarah Hurt
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20250224152208

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: DATE:
02/21/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Facility staff, Angelina EscobarTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident was not assisted with oxygen administration
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with Facility staff, Angelina Escobar, and Licensee Shanel Pronovost (over the phone) and explained the purpose of today’s visit.

Regarding the allegation that Resident was not assisted with oxygen administration. The investigation did not reveal sufficient evidence to support the allegation. Interviews with hospice nurses, caregivers, and the Administrator confirmed that oxygen equipment was present and functional in the resident’s room. Hospice records indicated the resident had an order for oxygen “as needed,” and documentation reflected that the resident sometimes refused or removed the nasal cannula. There was no evidence showing staff failed to assist or refused to provide oxygen when required. No adverse outcomes or missed treatments related to oxygen were documented by hospice. Based on interviews, record review, evidence does not support the allegation that the resident was not assisted with oxygen administration. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficincies Cited Per Title 22 Regulations. Exit interview conducted with Facility staff, Angelina Escobar , and a copy of this report along with appeals rights provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20250224152208
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: SOUTH PACIFIC VILLA
FACILITY NUMBER: 374604478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2026
Section Cited
CCR
87464(f)(1)
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87464 Basic Services
(f) Basic services shall at a minimum
include:(1) Care and supervision as
defined in Section 87101(c)(3) and Health andSafety Code section 1569.2(c).The following requirement has not been met as evidenced by:
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The licensee retrain all direct-care staff on: prroper turning and repositioning techniques,
pressure injury prevention, Monitoring and reporting changes in skin condition, and submit proof to LPA by POC date of 02/22/2026.
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The facility neglected to provide proper care
and supervision of Resident 1 leading to stage 1 pressure injury, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
02/22/2026
Section Cited
CCR
87625(a)(1)(2)
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87625 Managed Incontinence (a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances:(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered.(2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. The following requirement has not been met as evidenced by:
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The licensee will retrain all direct-care staff on timely response to incontinent care needs, proper hygiene practices, monitoring and reporting skin breakdown, rashes, or discomfort, and submit proof to LPA by POC date of 02/22/2026.
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Resident 1 was left soiled in urine and feces for extended periods of time contributing to a stage 1 pressure injury, which poses an immediate, heakth, safety, orpersonal rights risk to 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: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20250224152208
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: SOUTH PACIFIC VILLA
FACILITY NUMBER: 374604478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2026
Section Cited
CCR
87465(a)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.The following requirement has not been met as evidenced by:
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The licensee will ensure all staff responsible for medication assistance will receive retraining on medication administration procedures, including:
Administering medications strictly according to physician orders
Accurate documentation on the MAR
Identifying and reporting missed or refused doses immediately, and submi proof to LPA by POC date of 02/22/2026.
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Resident 1 was not given all prescribed medications, which poses an immediate health, safety, or personal rights risk to 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: See Moua
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5