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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604604
Report Date: 12/31/2025
Date Signed: 12/31/2025 06:06:06 PM

Unsubstantiated


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
12/15/2025 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20251215130522
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: 52DATE:
12/31/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director (ED) CameronTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not prevent the spread of gastrointestinal illness.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Correia conducted an unannounced visit to conclude a complaint investigation. LPA Correia was met by Executive Director (ED) Azemikah, identified herself, and explained the purpose of the visit.

On December 15, 2025, the Department received a complaint that alleged the Licensee did not prevent the spread of an illness. The Department’s investigation consisted of staff, resident, and outside source interviews, a facility tour, and a records review.

It was alleged that shortly after reopening the facility’s communal dining room, after undergoing renovations, residents in care experienced an outbreak of a gastrointestinal illness. An outside source alleged the illness was related to the food served at the facility.

On the same day the complaint was filed, December 15, 2025, the ED reported the outbreak to the Department.

[Continued on LIC 9099 C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025
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 2
Control Number 08-AS-20251215130522
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: 12/31/2025
NARRATIVE
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[Continuation of LIC 9099]

The ED disclosed they contacted the County Health Department who came to the facility to ensure infection control procedures and protocols were in place. LPA conducted an interview with Outside Source 1 (OS1) who corroborated and confirmed the ED’s statement. Also, during a facility tour LPA observed infection control procedures and protocol were in place.

A review of the facility log maintained of infected staff and residents revealed 6 staff and 26 residents were infected with the virus. Interviews conducted with one staff member (S1) revealed contracting the virus on December 9, 2025, 4 days before the facility re-opened communal dining on December 13, 2025, confirmed by a facility record review. An interview with Staff 2 (S2) revealed contracting the virus, however, they never ate at the facility.

A record review and interview with Resident 1 (R1) revealed they went to the hospital after displaying symptoms and tested positive for Norovirus. Additionally, an interview with Resident 2 (R2) revealed they did not contract the virus and revealed they ate all three meals at the facility while the communal dining was open.

Based on staff and resident interviews and records reviews the Department determined the allegation to be Unsubstantiated. An unsubstantiated finding means there was not a preponderance of evidence to prove the violation occurred.

An exit interview was conducted with ED Azemikah to whom a copy of this report (LIC 9099), and the Licensee Rights (LIC 9058) was provided. Signature below confirms receipt of the reports.

During today's visit LPA left for lunch and to conduct an additional visit.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Debbie Correia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025
LIC9099 (FAS) - (06/04)
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