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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604604
Report Date: 05/16/2023
Date Signed: 05/16/2023 04:16:26 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
05/09/2023 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230509134148
FACILITY NAME:PACIFICA SENIOR LIVING POWAYFACILITY NUMBER:
374604604
ADMINISTRATOR:AZEMIKHAH, CAMERONFACILITY TYPE:
740
ADDRESS:12750 GATEWAY PARK ROADTELEPHONE:
(858) 451-9933
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:72CENSUS: 45DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Marisol Barajas, Business Office ManagerTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Facility did not refund money owed after resident's death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced visit to commence a complaint investigation. LPA was granted entry after identifying herself. LPA discussed the purpose of the visit and the basic elements of the allegation mentioned above with Cheyenne Tillman, Resident Service Director, and Marisol Barajas, Business Office Manager (BOM). At the end of the visit, LPA made a determination of findings and delivered them to BOM.

On May 9, 2023, it was alleged that the facility did not refund money owed after resident’s death. The Department’s investigation consisted of review of facility records, and interviews with facility staff and outside sources.

Facility went through a change of ownership around February 2023, with a new license issued by the

[Contiued on LIC9099-C, Page 1 of 2]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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-20230509134148
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: PACIFICA SENIOR LIVING POWAY
FACILITY NUMBER: 374604604
VISIT DATE: 05/16/2023
NARRATIVE
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Department on March 7, 2023. During this transition, staff interviews revealed that four (4) residents had passed away and had not received their refund. Facility staff explained that once resident’s personal belongings are removed and keys for the room are returned, the BOM requests a refund from the facility’s corporate office. Refunds are approved and processed through the corporate office and not directly by the facility.

Staff interviews indicated that, due to the change of ownership, a new billing software was implemented. The ledger for February 2023 was not uploaded to the new system. Subsequently, the ledger created erroneous credits and charges. BOM requested corporate to assist with correcting the ledgers for Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3).

Facility records showed R1 passed on February 4, 2023. R1’s items were removed on February 10, 2023. BOM stated that R1’s ledger was corrected May 14, 2023 and a refund request to corporate would be submitted today, May 16, 2023.

R2 passed on February 15, 2023. R2’s items were removed on February 17, 2023. After corporate assisted BOM with ledger, a refund was requested by the facility to the corporate office on May 15, 2023. Facility records show that a refund was sent May 16, 2023. R3 passed on February 3, 2023.

R3’s items were removed on February 18, 2023. BOM stated that ledger will be corrected today, May 16, 2023, and a refund will be requested by the facility to the corporate office today as well.

Resident 4 (R4) passed on March 23, 2023. R4’s items were removed on March 31, 2023. Due to the date of death, the ledger had no issues being uploaded to the new system. A refund was requested by the facility to the corporate office on April 6, 2023. Facility records show that the refund was sent April 27, 2023.

Based on the evidence obtained during the complaint investigation, the allegation that the facility did not refund money owed after resident's death is found to be SUBSTANTIATED, as there is a preponderance of evidence to show the violation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed. An exit interview was conducted with BOM; a copy of this report and Licensee's Rights (LIC9058) were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20230509134148
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: PACIFICA SENIOR LIVING POWAY
FACILITY NUMBER: 374604604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited
HSC
1569.652(c)
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A refund of any fees paid in advance ... after the resident’s personal property has been removed from the facility shall be issued ... within 15 days after the personal property is removed. This requirement is not met as evidenced by:
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BOM agrees to show proof that refunds were requested for R1 and R3. BOM will also submit proof that refund was sent from corporate. BOM will submit tracking numbers for refunds.
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Based on interview and records review, the licensee failed to issue a refund within 15 days in 4 of 45 residents (R1, R2, R2, R4) which posed a potential 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: Denise Powell
LICENSING EVALUATOR NAME: Esther Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3