Inspection Reports for Pacific Gardens

An unannounced Required 1 Year visit was conducted to evaluate the facility's compliance with licensing requirements.

The Licensing Program Analyst toured the facility, reviewed resident and staff records, and inspected safety and medication storage. No deficiencies were cited during this inspection.

The visit was an unannounced complaint investigation triggered by allegations that a resident sustained an unexplained injury while in care and that facility staff did not seek timely medical attention for the resident.

The investigation included interviews with staff, residents, and review of records. Although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the allegations did or did not occur. Therefore, the allegations were unsubstantiated and no deficiencies were cited.

The complaint alleged that a resident sustained an unexplained injury and that staff failed to seek timely medical attention. The investigation included interviews with six staff members, three residents, and review of incident reports and progress notes. The resident was observed bleeding from the left elbow on 3/3/2025, received first aid, and was hospitalized for unrelated conditions. Staff reported the resident was a fall-risk and exhibited self-inflicted bruising during agitation. The allegations were found unsubstantiated due to lack of sufficient evidence.

The visit was an unannounced Case Management - Incident inspection conducted in response to an Incident Report received on 2025-02-05 regarding a medication error involving resident R1.

The investigation found that staff member S1 administered the wrong medication to resident R1 due to similar resident names but no adverse reaction occurred. The resident's physician and family were notified, and staff training records were reviewed. Further investigation was deemed necessary.

The complaint involved a medication error where resident R1 was given medication intended for resident R2 on 2025-02-02. The incident was reported, and no harm resulted. Staff admitted the error and training records were reviewed. The case management visit was initiated for further investigation.

The visit was an unannounced case management inspection to follow up on an Incident Report and Death Report related to a resident who sustained injury from a witnessed fall and subsequently passed away.

The Licensing Program Analyst conducted interviews and reviewed relevant documents including the resident's Physician's Report and staff training records. The case management visit determined that further investigation is needed.

An unannounced Required 1 Year visit was conducted to evaluate the facility's compliance with regulations.

The inspection found no deficiencies cited per California Code of Regulations, Title 22. Technical Violations were provided during the visit. Facility conditions including food supply, medication security, resident bedrooms, and safety equipment were observed to be in compliance.

An unannounced case management visit was conducted regarding an Incident Report received by the Department involving a resident who climbed out of a bedroom window and was found outside the building.

No deficiencies were cited during the visit. Technical Assistance and Technical Violation were provided. The facility has taken measures such as placing window stoppers in the resident's room and plans to install them on all windows in the Memory Care Department.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-08-04 regarding allegations including a resident denied a refund, staff not ensuring a resident ate resulting in weight loss, and resident's needs not being met.

The investigation found the complaint allegations to be unfounded after reviewing records, interviewing staff, and observing the facility. No deficiencies were cited. The resident's refund denial was due to failure to provide a 30-day notice as per the contract. The facility documented food intake and accommodated dietary preferences, and the resident's needs were met according to care plans and staff notes.

The complaint involved allegations that a resident was denied a refund, staff did not ensure the resident ate which resulted in weight loss, and the resident's needs were not met. The investigation included interviews with the Executive Director and review of resident records. The allegations were found to be unfounded.

The visit was an unannounced complaint investigation triggered by allegations received on 2021-10-25 that staff members yelled at residents and did not administer medications as prescribed.

Based on interviews with staff and residents, medication record reviews, and observations, the Department found the complaint allegations to be unfounded, meaning the allegations were false or without reasonable basis. No deficiencies were cited.

The complaint alleged that staff members yelled at residents and failed to administer medications as prescribed. Interviews with 7 staff and 6 residents denied these allegations. Medication record reviews of 3 residents showed no evidence of medication errors. Staff interviews confirmed medications were only not given when residents refused. The allegations were determined to be unfounded.

The visit was an unannounced complaint investigation triggered by an allegation received on 12/20/2021 that staff did not distribute residents' medications as prescribed.

Based on observation, interviews with staff and residents, and medication record reviews, the Department found the complaint allegation to be unfounded. No deficiencies were cited as the allegation was determined to be false or without reasonable basis.

The complaint alleged that staff did not administer medications as prescribed. Investigators reviewed medication records for 3 residents and interviewed 3 staff members who denied the allegation. The investigation concluded the allegation was unfounded.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements for the assisted living and memory care facility.

The facility was generally found to be clean and well-maintained with proper safety measures such as fire alarms and extinguishers in place. However, a technical violation was cited due to the presence of over-the-counter medication in a resident's room without a physician's order or administrator knowledge.

An unannounced Infection Control site visit was conducted as a required 1-year inspection to evaluate the facility's compliance with COVID-19 related infection control policies and procedures.

The facility was found to have appropriate infection control measures in place, including symptom screening, PPE use, hygiene supplies, and clear fire exit routes. No deficiencies were issued during this inspection.

The visit was an unannounced complaint investigation triggered by an allegation that an eviction notice issued to a resident did not meet SB781 Eviction Procedure requirements.

The investigation found no preponderance of evidence to prove the allegations. The eviction notice and related documentation were reviewed, and the complaint was determined to be unsubstantiated. No citations were issued.

The complaint alleged that the eviction notice issued to resident R1 did not meet SB781 Eviction Procedure. The investigation included review of the eviction notice, behavior logs, and interviews. The allegations were found to be unsubstantiated.

The visit was an unannounced Case Management follow-up on a report received regarding a resident who fell off the back of the company van on 06/30/2021.

The investigation found no deficiencies; the van's safety features were functional, and the driver was properly trained and supervised. The incident was witnessed only by the driver, and no evidence of lack of supervision was found.

The visit was complaint-related following a report of a resident fall from the company van. The complaint was investigated and found to have no substantiated deficiencies.

The visit was an unannounced Case Management tele-visit to obtain additional information regarding the death of a resident at the facility premises on 03/12/2021.

No deficiencies were cited during the tele-visit. The Licensing Program Analyst interviewed the Executive Director and requested copies of the resident's records to complete the investigation.

The visit was triggered by a resident death reported on 03/12/2021. The resident was found unresponsive and declared deceased by paramedics. The department reviewed the death report and conducted the investigation accordingly.