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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601046
Report Date: 07/17/2025
Date Signed: 07/17/2025 01:10:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/21/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250121131044
FACILITY NAME:PACIFICA SENIOR LIVING MISSION VILLAFACILITY NUMBER:
415601046
ADMINISTRATOR:SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:995 E MARKET STTELEPHONE:
(650) 756-1995
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:60CENSUS: 56DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Shayan GheisarTIME COMPLETED:
01:23 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident sustaining multiple fractures.
Staff did not seek medical attention to resident in a timely manner.
Staff did not communicate with resident's responsible party.
INVESTIGATION FINDINGS:
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On July 17, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Shayan Gheisar and explained the purpose of the visit.

Regarding the allegation, staff did not provide adequate supervision resulting in resident sustaining multiple fractures, according to the reporting party, on 12/2/24, Resident 1 (R1) fell in his/her bedroom and sustained a skin tear on his/her elbow. On 12/4/24, it was observed that R1 was in pain and paramedics were called. The paramedics pointed out that R1’s leg was in a weird position and might have suffered a broken hip and leg. It was later revealed that R1 suffered pelvic fractures in three different places.

During the investigation, the Department interviewed staff, reviewed R1’s file and reviewed medical records. According to R1’s service plan, it was indicated that R1 was a fall risk, required two-persons transfer, escort assistance and close supervision. Additionally, R1’s narrative charting notes had over 30 notes documenting R1’s numerous attempts to get up from his/her wheelchair. (continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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 5
Control Number 14-AS-20250121131044
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046
VISIT DATE: 07/17/2025
NARRATIVE
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Despite the facility being aware of R1’s behavior and condition, facility staff did not assist a Vitas Healthcare hospice aide on 12/2/24, leaving the hospice aide alone with R1. Facility staff interviewed acknowledged that facility caregivers did not help provide care to R1 when the hospice staff visited. According to the hospice aide interviewed, he/she transferred R1 alone despite staff knowing R1 required a two-person transfer. According to facility staff interviewed, it was indicated that even though there are two or more caregivers monitoring majority of the residents in the dining room throughout the day, residents can still fall.
 
Based on R1’s medical records reviewed, the hospital noted R1 had a rotation to his/her left leg and a deformity to his/her left hip. Although R1 initially denied experiencing pain after his/her fall, R1 did complain of pain to his/her left hip and refused to eat. R1’s Computed Tomography (CT) scan showed an acute, mildly displaced fracture of the left iliac wing extending to the acetabulum with associated widening of the left femoroacetabular joint space; an acute, comminuted, mildly displaced fracture of the left inferior pubic ramus, and a mild presacral edema without a definite sacral fracture. A hematoma involving the left iliacus and left pelvic sidewall was also present on the scan. On 12/19/2024, R1 passed away. One of the primary causes of R1’s death noted on his/her death certificate was pelvic fractures (months).

Regarding the allegation, staff did not seek medical attention to resident in a timely manner, according to the reporting party, on 12/2/24 at around 7am, Resident 1 (R1) fell and sustained a skin tear but was observed to be fine according to the hospice nurse. However, on 12/4/24, Vitas Healthcare hospice aide observed R1 in pain. R1 was taken to the hospital and was found to have suffered pelvic fractures in three different places.
 
During the investigation, the Department reviewed R1’s file, medical records, and interviewed staff. Based on documentation reviewed, on 12/2/24, R1 had a fall while a hospice aide was present. R1 sustained a right arm skin tear and was treated by the hospice nurse. The hospice nurse instructed staff to closely monitor R1. According to staff interviewed, it was noted that later in the evening of 12/2/24, R1 was constantly yelling for help. Staff 1 (S1) notified R1’s responsible party of R1’s pain and the responsible party requested for the med-tech to administer Tylenol to R1 as needed for pain, as R1’s responsible party believed that R1 might be hiding his/her pain. On 12/3/2024, Staff 2 (S2) indicated R1 was complaining of pain when changing R1’s diaper and reported it to the med-tech, however there was nothing documented regarding R1’s pain. Former staff member (S3) noted that R1 was constantly yelling for help,  was agitated all morning, and refused to eat his/her meals as he/she normally would. (continue to 9099C)
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20250121131044
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046
VISIT DATE: 07/17/2025
NARRATIVE
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 It was not until the following evening on 12/4/24 that R1 was sent out to the hospital after S1 noted R1 complaining of left hip pain. Staff interviewed were unable to state why R1 was not sent out to the hospital earlier. Documentation reviewed showed that R1 was complaining of pain the night of 12/2/24, was constantly yelling for help, was noted to be more agitated than normal, and refused to eat signaling a change in condition.

Regarding the allegation, staff did not communicate with resident's responsible party, according to the reporting party, after R1 had a fall on 12/2/24 at around 7am, the facility did not communicate with R1's responsible party regarding R1 complaining of pain. In addition, the reporting party stated that it was not until the hospice nurse called R1's responsible party on 12/4/24 and was told by R1's responsible party to send R1 to the hospital.

During the investigation, LPA interviewed the administrator and reviewed R1's charting notes. According to the charting notes reviewed, Although, R1's responsible party was notified of R1's fall on 12/2/24 and notified of R1 not eating later in the evening, the facility did not communicate with R1's responsible party on 12/3/24, when R1 was constantly yelling for help and documented a change in R1's condition. According to the administrator, R1's responsible party was notified of R1's change of condition on 12/2/24 and indicated if a resident is on hospice, hospice instructs the facility not to call 911.

Based on information collected, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties.

An immediate $500 civil penalty is being assessed today as the facility did not provide adequate supervision resulting in R1 sustaining multiple fractures in care. A repeat civil penalty of $500 is being issued today due to the same violation (87464(f)(1) Basic Services) being cited on 1/9/2025. Due to immediate civil penalty of $500 being cited and repeat civil penalty of $500 being issued, total civil penalty being assessed today is $1,000.

An immediate $500 civil penalty is being assessed today as staff did not seek medical attention to resident in a timely manner.

THE ADMINISTRATOR WAS INFORMED THAT AN ADDITIONAL CIVIL PENALTY IS STILL BEING DETERMINED AND MIGHT BE ASSESSED BASED ON HEALTH AND SAFETY CODE §1569.49. Report is reviewed with Administrator and a copy is provided with appeal rights. A copy of civil penalties are provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20250121131044
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
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 and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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Licensee/administrator shall conduct an in-service to ensure staff are closely monitoring residents if they are identified to be a fall risk.
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Based on interviews and records reviewed, R1 was a fall risk, required two-persons transfer, escort assistance and close supervision, however despite staff being aware, facility staff did not assist a Vitas Healthcare hospice aide on 12/2/24, leaving the hospice aide alone with R1. In addition, R1 fell on 12/2/24, and based on medical records, R1 had a rotation to his/her left leg and a deformity to his/her left hip, an acute, mildly displaced fracture of the left iliac wing extending to the acetabulum with associated widening of the left femoroacetabular joint space; an acute, comminuted, mildly displaced fracture of the left inferior pubic ramus, and a mild presacral edema without a definite sacral fracture. A hematoma involving the left iliacus and left pelvic sidewall was also present. This poses an immediate health and safety risk to residents in care.
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An immediate $500 civil penalty is being assessed today as the facility did not provide adequate supervision resulting in R1 sustaining multiple fractures in care.

A repeat civil penalty of $500 is being issued today due to the same violation being cited on 1/9/2025.

Due to immediate civil penatly of $500 being cited and repeat civil penalty of $500 being issued, total civil penalty being assessed today is $1,000.
Type A
07/18/2025
Section Cited
CCR
87465(a)(1)
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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... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not me as evidenced by:
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Licensee/administrator shall conduct an in-service training to ensure staff notify families regarding any changes of condition. Training shall include, notifying physician and sending resident out when there is a change of condition.
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Based on documentation reviewed, R1 had a fall on 12/2/24 at 7am and was treated by the hospice nurse. However, it was noted that later in the evening of 12/2/24, R1 was constantly yelling for help. Based on staff interviews, on 12/3/2024, R1 was complaining of pain when changing R1’s diaper and reported it to the med-tech and constantly yelling for help. It was not until the following evening on 12/4/24 that R1 was sent out to the hospital after staff noted R1 complaining of left hip pain. Staff interviewed were unable to state why R1 was not sent out to the hospital earlier which poses an immediate health and safety risk to residents in care.
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An immediate $500 civil penalty is being assessed today as staff did not seek medical attention to resident in a timely manner.
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: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20250121131044
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PACIFICA SENIOR LIVING MISSION VILLA
FACILITY NUMBER: 415601046
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
Section Cited
CCR
87463(f)
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87463 Reappraisals: (f) The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation...

This regulation is not met as evidenced by:
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Licensee/administrator shall conduct an in-service training to ensure staff notify families and any required parties regarding a change of resident condition. .
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Based on R1's charting notes reviewed, although the facility did reach out to R1's responsible party on 12/2/24 after the fall and later in the evening, the facility failed to communicate with R1's responsible party on 12/3/24 when R1 was constantly yelling for help and the facility documented a change in R1's condition which poses an immediate health and safety 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: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5