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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604604
Report Date: 02/23/2024
Date Signed: 02/23/2024 11:34:03 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
04/24/2023 and conducted by Evaluator Nacole Patterson
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20230424144236
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: 40DATE:
02/23/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Cameron Azemikhah, Executive DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility was not communicating their visitation policy.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Cameron Azemikhah, Executive Director.

On 4/24/23 it was alleged that the facility was not communicating their visitation policy, due to residents not being given access inside the building at night. The Department’s investigation consisted of unannounced facility visits, review of facility records, interviews with facility staff, residents, outside sources, and LPA direct observations. Staff interviews corroborated the allegation, staff informing that timeliness in assisting residents with access to the building at night had been an ongoing issue. Staff interview further revealed that the facility's phone system was inconsistent, causing some calls to not go through, resulting in staff not being aware that someone was at the door. Staff interview, confirmed by records review, showed that residents brought the issue up during resident council meetings and communicated their concerns to staff, in writing. (Continued on LIC9099-C p.2)
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
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 6
Control Number 08-AS-20230424144236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PACIFICA SENIOR LIVING POWAY
FACILITY NUMBER: 374604604
VISIT DATE: 02/23/2024
NARRATIVE
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(Continued from LIC9099 p.1)

Resident interviews also corroborated the allegation, residents stating that they waited outside up to 1.5 hours for staff to answer the phone and come to the door to let them in.

Outside source interview corroborated the allegation, confirming that residents were waiting for long periods of time after hours, unable to get into the building.

Review of the Resident Handbook, Appendix E of the Residence and Care Agreement, revealed the following policy regarding access to the building after hours: "When visiting after hours, please call [facility phone number] and/or press the call button located on the front door to enter and exit the community after hours". On 4/27/23, 1/30/24, and 2/10/24, Department staff contacted the facility number after hours, which produced varied response times. On 4/27/23, one (1) call was made to the facility phone, which was answered within 18 seconds. On 1/30/24, the phone was answered within 3 seconds on two (2) separate after hours calls. On 2/10/24, six (6) calls were made after hours over the span of 43 minutes at 10:03pm, 10:05pm, 10:16pm, 10:25pm, 10:34pm, and 10:46pm. The phone was not answered on any call on 2/10/24 and went to voicemail each time.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred, and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Cameron Azemikhah, Executive Director, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20230424144236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFICA SENIOR LIVING POWAY
FACILITY NUMBER: 374604604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2024
Section Cited
CCR
87507(f)
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87507(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
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Executive Director (ED) agreed to retrain all staff on the duties/expectations for resident access after hours. ED agreed to audit door response times for March to ensure timeliness for resident access into the building. ED will ensure all phones are in working order or replace them.
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Based on records and interviews, Licensee did not comply with the terms set forth in the Admission Agreement regarding access to the building. This posed a personal rights and health and safety risk to 40 of 40 residents in care.
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ED agreed to update the door answering protocol, prioritizing pushing the button before calling the facility phone. ED will update the Resident Handbook, notify residents in the Town Hall meeting 2/27/24 and a community-wide letter. ED to submit documents by POC Due date.
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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: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 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
04/24/2023 and conducted by Evaluator Nacole Patterson
COMPLAINT CONTROL NUMBER: 08-AS-20230424144236

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: 40DATE:
02/23/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Cameron Azemikhah, Executive DirectorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility staff were not considerate of resident's food preference.
Facility staff did not serve hot food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Cameron Azemikhah, Executive Director.

On 4/24/23 it was alleged that facility staff were not considerate of a resident's food preference, and that facility staff did not serve hot food. The Department’s investigation consisted of unannounced facility visits, review of facility and outside source records, interviews with facility staff, residents, outside sources, and LPA direct observations.

Regarding the allegation, "Facility staff were not considerate of resident's food preference", Staff interview revealed that the facility offered a variety of food options for residents, which varied by day, week, and month. Staff members interviewed informed that the facility offered a menu of everyday options in addition to the entrée. (Continued on LIC9099-C p.2)
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20230424144236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PACIFICA SENIOR LIVING POWAY
FACILITY NUMBER: 374604604
VISIT DATE: 02/23/2024
NARRATIVE
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(Continued from LIC9099 p.1)

Staff interview further revealed that the chef held monthly meetings with residents regarding the menu to discuss any issues with food service. The chef informed that they used low sodium broth in all soups and did not add salt to any dish, as salt and pepper were provided on each table. Menu items notated if an item/spice was included, such as garlic or onions. Resident interviews revealed that while residents had specific distastes of certain menu items, the facility offered other food options for all meals, and residents were able to choose alternative meals to their preference.

Outside source interview did not corroborate the allegation of resident food preferences not being honored.

Review of facility records showed that the Licensee held documentation of dietary restrictions for residents, which were adhered to by kitchen staff. The documentation showed communication about a vegan diets, lactose intolerance, coffee preferences, and a low sodium diet. LPA reviewed the menu offerings for the month of January 2024, which showed that residents had the option to choose from 16 alternate menu items in addition to the daily entrees. LPA observed options of at least 17 breakfast, 25 lunch, and 25 dinner entrees offered to residents.

LPA directly observed the low sodium broth used to prepare soups, as well as salt and pepper shakers and other condiments on the dining room tables.

Regarding the allegation, "Facility staff did not serve hot food", it was alleged that the Assisted Living residents food was served to them cold, due to the food being made in a separate building. Staff interview revealed that staff measured, monitored, and documented food temperatures during preparation. Staff interview revealed that the meals were prepared in the large main kitchen, and transported in steam trays on carts to the Assisted Living building. Staff interview further informed that the steam trays kept the food hot throughout the transport and serving process. Resident interviews did not corroborate the allegation, as residents did not express concern with food temperatures during meals.

(Continued on LIC9099-C p.3)
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20230424144236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: PACIFICA SENIOR LIVING POWAY
FACILITY NUMBER: 374604604
VISIT DATE: 02/23/2024
NARRATIVE
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(Continued from LIC9099-C p.2)

Outside source interview did not corroborate the allegation of resident food not being served hot.

Records review corroborated staff statements regarding the monitoring and documentation of food temperatures. LPA observed a document in the main kitchen labeled, "Food Taste and Temperature Log", with each food item, date, temperature, and the initial of the kitchen staff who tested it. During an unannounced facility visit, LPA directly observed the steam trays used to transport and keep food warm. LPA did not observe any issues with the food temperatures.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Cameron Azemikhah, Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6