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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604604
Report Date: 10/20/2023
Date Signed: 10/20/2023 04:21:06 PM

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
09/29/2023 and conducted by Evaluator Marisela Garcia-Centeno
COMPLAINT CONTROL NUMBER: 08-AS-20230929161749
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: 38DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Resident Servicess Director, Cheyenne TillmanTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Staff did not meet resident's incontinence care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced visit to deliver investigative findings. LPA met with Resident Services Director, Cheyenne Tillman, and shared findings.

The Department investigated the above-listed complaint allegation. The investigation consisted of observations, multiple interviews with staff, residents, and outside sources and a detailed review of relevant records.

On September 29, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not meet a resident’s (R1) incontinence care needs, [an LIC 811 Confidential Names List was provided to staff to identify the resident].

(continue at LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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 4
Control Number 08-AS-20230929161749
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 POWAY
FACILITY NUMBER: 374604604
VISIT DATE: 10/20/2023
NARRATIVE
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continue from LIC 9099

During multiple interviews with staff, residents, and outside sources, it was consistently indicated that the facility did not have sufficient staff to meet resident’s needs. During interviews with multiple residents with total assistance needs for all activities of daily living including toileting, it was consistently indicated residents were left with soiled briefs for extended periods of time. The residents consistently stated that there were times they did not get incontinence care for 4 to 5 hours during the day shift, and at times even longer. The same concerns were voiced during interviews with outside sources. In addition, interviews with outside source medical providers indicated that some total assist residents who were bedbound and needed to be repositioned every two hours, as required in their service care plans, did not get repositioned or changCed from 10 p.m. until 5 or 6 a.m. the following morning. During the investigation, an incident when a total assist resident was left in a soiled brief for more than 13 hours was disclosed. On Thursday, October 12, 2023, at 10:24 a.m. an outside source found a resident with an extremely soaked brief marked with “9:00 p.m.” and the staff member's initials. The staff member who marked and initialed the brief confirmed the information was correct. A picture of the resident’s soiled brief was reviewed during the investigation.

Multiple interviews with staff and residents indicated there was a high level of employee turnover since the facility change of ownership that took place on March 7, 2023. Management indicated that seven (7) care staff left the facility in early September 2023. In addition, during interviews, staff indicated that although they were working double shifts to provide adequate coverage to meet the needs of residents, at times there were no available caregivers to work during unforeseen callouts. Based on the review of the work schedule for the months of September and October 2023 it appeared that for the most part, there were enough caregivers scheduled to work per shift. However, there were times when caregivers called out and it wasn't clear which caregiver provided coverage on that day or if coverage was provided.

The Executive Director indicated that the facility had a current contract with a temporary agency for caregivers. However, according to management, the facility did not employ caregivers from the temporary agency because they were able to meet the needs of the residents with the current staff working double shifts. Management indicated that October 13, 2023, was the first time the facility did not have enough caregivers and employed caregivers from the temporary agency to provide coverage during the night shift.
(continue at LIC9099C)
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 08-AS-20230929161749
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 POWAY
FACILITY NUMBER: 374604604
VISIT DATE: 10/20/2023
NARRATIVE
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Continue from LIC 9099C

Based on observations, records review, and interviews with staff, residents, and outside sources, there was sufficient evidence to support the allegation that staff did not meet the resident’s incontinence care needs.

The Department has investigated the above-mentioned allegations and has found that there was sufficient evidence to corroborate the allegations. Therefore, this allegation is deemed to be substantiated. A substantiated finding means the allegation is valid because the preponderance of the evidence standard has been met. A Deficiency was cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations and is listed on LIC 9099-D. A plan of correction was developed with the Resident Services Director, Tillman.

A copy of this report, LIC 9099D, LIC811 Confidential names along with Licensee/Appeal Rights (LIC 9058 03/22) was provided to Resident Services Director, Tillman, at the end of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20230929161749
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 POWAY
FACILITY NUMBER: 374604604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/24/2023
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement was not met as evidenced by:

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The licensee agreed to review their personnel/staffing requirements and update the plan of operations to ensure facility personnel is sufficient in number and competent to meet residents' needs. The licensee will submit a revised plan of operations to CCL by the POC date of 11-24-2023.
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Based on interviews and a review of records, the licensee did not ensure the facility was sufficiently staffed to meet the needs of five (5) residents. This posed an immediate health and safety risk to five (5) residents in care.
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In addition, the licensee agreed to develop and implement internal procedures to ensure accountatbility that care staff are providieng services to residents according the the needs and services plans. The plan will be submitted to CCL by POC date of 11/24/2023.
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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: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4