Inspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating generally good compliance with regulations. The most recent report from July 18, 2025, found no health or safety issues and noted the facility was clean and organized. Earlier reports showed isolated deficiencies related mainly to personnel records, maintenance issues like plumbing and air conditioning repairs, and medication administration errors, with no fines or enforcement actions listed in the available reports. A more serious complaint investigation in January 2021 substantiated failures to seek timely medical attention, inappropriate staff comments, and blocked exits, with a pending civil penalty up to $10,000. Since then, the facility appears to have improved, with recent inspections consistently reporting no deficiencies and complaints largely unsubstantiated.
Deficiencies per Year
8
6
4
2
0
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Census: 54
Capacity: 98
Deficiencies: 0
Jul 18, 2025
Visit Reason
This unannounced inspection was conducted by Licensing Program Analyst Fred Arias for the purpose of a health and safety check.
Findings
The Licensing Program Analyst toured the facility, conducted health and safety checks on residents, and found no health and safety issues. The facility was observed to be clean and organized.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yaylene Mazariegos | Administrator | Met with Licensing Program Analyst during inspection and discussed the purpose of the inspection. |
| Fred Arias | Licensing Program Analyst | Conducted the inspection and health and safety checks. |
Inspection Report
Census: 49
Capacity: 98
Deficiencies: 0
Jun 17, 2025
Visit Reason
This unannounced inspection was conducted for the purpose of a health and safety check by Licensing Program Analyst Fred Arias, who met with the facility Administrator Yaylene Mazariegos.
Findings
The inspection found no health or safety issues; the facility was clean and organized, with proper food supplies, running utilities, and properly stored medications. Resident and staff rosters and files were reviewed.
Report Facts
Food supply duration: 2
Food supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yaylene Mazariegos | Administrator | Met with Licensing Program Analyst during inspection |
| Fred Arias | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Annual Inspection
Census: 35
Capacity: 98
Deficiencies: 0
Apr 25, 2025
Visit Reason
An unannounced required annual visit was conducted to evaluate compliance with licensing requirements for the facility.
Findings
The facility was found to be in compliance with all applicable regulations with no deficiencies cited. The physical plant, food service, documentation, emergency systems, and resident and staff files were all reviewed and found satisfactory.
Report Facts
Licensed capacity: 98
Current census: 35
Hospice waiver capacity: 20
Fire alarm annual inspection date: Mar 5, 2025
Last emergency drill date: Mar 10, 2025
Water temperature range (F): 105.4-115.8
Call response time (minutes): 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Fred Arias | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Yaylene Mazariegos | Executive Director | Facility representative who conducted the tour and provided documentation. |
Inspection Report
Capacity: 98
Deficiencies: 0
Apr 4, 2025
Visit Reason
The visit was conducted to verify the Chapter 7 Bankruptcy Report filed by Pacifica Senior Living as reported by the media.
Findings
The report details that despite multiple lawsuits against the company, there is no financial impact on the properties, residents, or staff. Management communicated that Pacifica Senior Living Management was no longer managing the communities, and there were no vendor issues or other pending suits against the entities.
Report Facts
Lawsuit amount: 25000000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Knepler | Chief Executive Officer | Provided information regarding lawsuits and financial impact |
| Stacy Barlow | Assistant Program Administrator | Conducted the meeting to verify bankruptcy report |
| Shelly Gracce | Assistant Branch Chief, CCLD | Present during the meeting |
| Craig Lundgren | Legal Counsel, CCLD | Present during the meeting |
| Marlene Nelson | Director, Quality Assurance and Risk Management | Present during the meeting |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 98
Deficiencies: 0
Mar 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to complaints alleging inadequate staffing and inadequate provision of hygiene supplies at the facility.
Findings
The investigation found that staffing levels were adequate with trained staff able to assist residents, and hygiene supplies were available to residents as needed. Interviews and observations led to the determination that the allegations were unsubstantiated.
Complaint Details
The complaint was received on 2025-03-13 and investigated on 2025-03-21. Allegations included inadequate staffing and inadequate hygiene supplies. The investigation concluded the allegations were unsubstantiated based on interviews, observations, and documentation.
Report Facts
Facility capacity: 98
Current census: 34
Staffing counts: 1
Staffing counts: 1
Staffing counts: 1
Staffing counts: 2
Staffing counts: 1
Staffing counts: 1
Residents in assisted living: 18
Residents in memory care: 16
Residents under incontinent care: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the complaint investigation |
| Yaylene Mazariegos | Executive Director | Provided information and interviews during investigation |
| Patrick McAdoo-Morton | Administrator | Named as facility administrator |
| Alisa Ortiz | Licensing Program Manager | Named as licensing program manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 98
Deficiencies: 0
Mar 12, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff prevented a resident's medical professional from caring for the resident and that the facility did not provide the resident's authorized representative with a written refund policy in a timely manner, among other complaints.
Findings
The investigation found the allegation that staff prevented the resident's medical professional from providing care to be unfounded. Other allegations regarding timely medical attention, safeguarding personal belongings, and communication with the authorized representative were unsubstantiated due to conflicting information and lack of preponderance of evidence.
Complaint Details
The complaint investigation was triggered by multiple allegations including staff preventing medical care, failure to provide written refund policy timely, delayed medical attention, failure to safeguard personal belongings, and poor communication with the authorized representative. The allegation of preventing medical care was found unfounded, while the others were unsubstantiated.
Report Facts
Capacity: 98
Census: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia Gutierrez | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Yaylene Mazariegos | Executive Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 98
Deficiencies: 0
Feb 19, 2025
Visit Reason
An unannounced complaint investigation was conducted to examine allegations that the facility did not safeguard a resident's cellphone which led to its theft and that the facility did not follow their theft and loss policy regarding the theft of the resident's cellphone.
Findings
The investigation found no corroborating evidence that the resident's cellphone or hearing aid were stolen or that the facility failed to follow its theft and loss policy. The facility staff and residents denied the allegations, and the missing cellphone was later found. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint involved allegations that the facility did not safeguard a resident's cellphone leading to theft and did not follow theft and loss policies. The investigation included interviews with staff, residents, and review of documents. The allegations were unsubstantiated as evidence did not support the claims.
Report Facts
Facility capacity: 98
Resident census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sean Haddad | Licensing Program Analyst | Conducted the complaint investigation |
| Armando J Lucero | Licensing Program Manager | Oversaw the complaint investigation |
| Yaylene Mazariegos | Administrator | Interviewed during investigation |
| Staff #1 | Staff who oversaw investigation into resident's missing property and denied allegations |
Inspection Report
Census: 35
Capacity: 98
Deficiencies: 0
Jul 3, 2024
Visit Reason
An unannounced health and safety case management visit was conducted in conjunction with an SOC 341 received by the department on 06/24/2024.
Findings
The facility was found to be clean and sanitary with no health or safety concerns observed. Residents expressed satisfaction and felt safe. Records for one resident were reviewed including physician report, pre-appraisal, and medication orders.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced health and safety case management visit. |
| Stacie Anderson | Administrator | Facility administrator who greeted the Licensing Program Analyst and was met with during the visit. |
Inspection Report
Annual Inspection
Census: 34
Capacity: 98
Deficiencies: 2
Jun 12, 2024
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced visit to conduct the required annual inspection of Pacifica Senior Living South Coast facility.
Findings
The facility was generally clean and operational with no discrepancies in resident files or medications. However, deficiencies were found in personnel records, including missing health screenings in 3 of 5 staff files and lack of current training documentation in 2 of 2 caregiver files. The first aid kit lacked a current edition manual.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Personnel records missing health screenings in 3 out of 5 staff files. | Type B |
| Caregiver files missing current training documentation in 2 out of 2 files. | Type B |
Report Facts
Hot water temperature range: 110
Hot water temperature range: 115
Staff files reviewed: 5
Caregiver files reviewed: 2
Staff files missing health screening: 3
Caregiver files missing current training: 2
Plan of Correction Due Date: Jun 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stacie Anderson | Executive Director / Administrator | Met with Licensing Program Analyst during inspection |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 98
Deficiencies: 0
Dec 21, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-27 alleging multiple issues including failure to follow infection control protocols, improper staff training, lack of resident activities, lack of care and supervision, and understaffing.
Findings
After conducting 9 interviews with residents and staff, reviewing documentation, and touring the facility, the Licensing Program Analyst found no corroboration of the allegations. The facility was observed to have adequate infection control supplies, documented staff training, ongoing resident activities, sufficient care and supervision, and appropriate staffing levels. Therefore, the allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to follow infection control protocols, improper staff training, lack of activities, lack of care and supervision, and understaffing. Interviews and documentation review did not support these allegations.
Report Facts
Capacity: 98
Census: 33
Number of interviews conducted: 9
Staff per shift: 5
Staff schedule review period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kimberly Melendez | Community Relations Director | Met with Licensing Program Analyst during the visit |
| Yesenia Castro | Business Office Manager | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 98
Deficiencies: 0
Aug 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility failed to provide a refund to a responsible party.
Findings
The allegation was found to be unfounded after interviews and record reviews confirmed that the refund process had been initiated, the refund check was mailed, and the responsible party confirmed receipt of the refund. No citations were issued.
Complaint Details
The complaint alleged that the facility failed to provide a refund to the responsible party. The investigation included six interviews and record reviews. The refund was mailed on 07/20/2023, the responsible party was contacted on 07/21/2023, and confirmed receipt on 07/31/2023. The allegation was determined to be unfounded.
Report Facts
Capacity: 98
Census: 37
Number of interviews conducted: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Stacie Anderson | Executive Director | Met with Licensing Program Analyst during the visit and involved in refund process |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 98
Deficiencies: 5
Jun 14, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that the facility failed to provide care and supervision to a resident resulting in death, and other related complaints including failure to seek medical attention, observe resident for change in condition, report incidents, refund responsible party, and release records.
Findings
The investigation found that staff failed to call 911 after the resident's unwitnessed fall, did not properly observe or assess the resident's change in condition, failed to report incidents to appropriate parties, delayed refunding the responsible party, and delayed providing resident records. The allegation of failure to provide care resulting in death was unsubstantiated.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to provide care and supervision to a resident resulting in death, failed to seek medical attention after a fall, failed to observe the resident for change in condition, failed to report incidents to appropriate parties, failed to refund the responsible party after the resident's death, and failed to release records to the responsible party. The investigation substantiated all allegations except the failure to provide care resulting in death, which was unsubstantiated.
Severity Breakdown
Type A: 2
Type B: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to call 911 following resident's unwitnessed fall on 04/10/2022, posing immediate risk to resident health and safety. | Type A |
| Failed to regularly observe resident for changes in condition following unwitnessed fall on 04/10/2022. | Type A |
| Failed to submit required Incident and Death Reports to Licensing for resident. | Type B |
| Failed to provide resident records to legal representative in a timely manner. | Type B |
| Failed to provide refunds of funds paid in advance in a timely manner after resident's death. | Type B |
Report Facts
Capacity: 98
Census: 41
Refund amount: 2411.18
Additional refund owed: 1500
Fall date: Apr 10, 2022
Resident death date: Apr 13, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation |
| Stacie Anderson | Executive Director | Facility representative met during investigation and exit interview |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Staff 5 | Medication Technician involved in fall incident and reporting | |
| Staff 1 | Staff notified of fall and involved in resident observation | |
| Staff 7 | First caregiver to find resident after fall | |
| Staff 8 | Caregiver who observed resident's change in condition | |
| Staff 6 | Medication Technician | Assisted in dressing resident and observed injury |
| Staff 2 | Submitted refund request | |
| Staff 4 | Confirmed failure to submit incident and death reports | |
| Staff 10 | Assisted Staff 5 in helping resident after fall |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 98
Deficiencies: 1
Jun 14, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2023-04-18 regarding multiple allegations including resident comfort, food temperature, notification of incidents, unauthorized services, and plumbing issues.
Findings
The investigation found the allegations regarding resident comfort, food temperature, notification of incidents, and unauthorized services to be unsubstantiated due to conflicting statements and lack of corroborating evidence. However, the allegation that a resident's toilet was in disrepair was substantiated, with plumbing issues confirmed and subsequently corrected prior to the visit.
Complaint Details
The complaint investigation was unannounced and conducted by Evaluator Patricia Velazquez. Allegations included staff not ensuring resident comfort, food served cold, failure to notify responsible party of incidents, unauthorized services, and a resident's toilet in disrepair. The first four allegations were unsubstantiated due to conflicting statements and lack of evidence. The toilet disrepair allegation was substantiated but corrected prior to the visit.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Toilet, handwashing and bathing facilities shall be maintained in operating condition. This requirement was not met as evidenced by: based on record review and interview the Licensee did not ensure the toilets were properly maintained. This poses a potential risk to the health & safety of residents in care. | Type B |
Report Facts
Capacity: 98
Census: 41
Deficiencies cited: 1
Plan of Correction Due Date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Stacie Anderson | Executive Director | Met with Licensing Program Analyst during the investigation and named in findings |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 98
Deficiencies: 1
Apr 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not administer residents' medications as prescribed.
Findings
The investigation found that medications for two residents were not administered as prescribed due to missing medications at the facility, confirming the allegation as substantiated.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews confirming that medications were not administered as prescribed.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care. The licensee did not ensure medications for residents R1 and R2 were given according to physician's orders, posing an immediate risk to health and safety. | Type A |
Report Facts
Capacity: 98
Census: 43
Deficiencies cited: 1
Plan of Correction Due Date: Apr 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and documented findings |
| Stacie Anderson | Executive Director | Facility representative met during investigation and named in exit interview |
| Jennifer Thompson | Resident Care Director, L.V.N. | Assisted in medication review and confirmed medication administration issues |
| Sheila Santos | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 98
Deficiencies: 1
Mar 9, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including resident dehydration, falls, uncomfortable temperature, inadequate drinking supplies, and staff not following posted activities schedule.
Findings
The investigation found conflicting statements from interviewed individuals and insufficient evidence to substantiate most allegations, deeming them unsubstantiated. However, the allegation that the air conditioner was in disrepair was substantiated, citing a violation of maintenance and operation requirements. The furnace and AC units were repaired and the citation was cleared at the time of the visit.
Complaint Details
The complaint investigation was unannounced and triggered by allegations received on 09/13/2022. Ten individuals interviewed provided conflicting statements and could not corroborate most allegations, which were deemed unsubstantiated. The air conditioner disrepair allegation was substantiated based on record review and observations.
Deficiencies (1)
| Description |
|---|
| Maintenance and Operation. The facility did not ensure the furnace and AC units were in operating condition, posing a potential risk to the health and safety of residents. |
Report Facts
Capacity: 98
Census: 48
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Stacie Anderson | Executive Director | Met with Licensing Program Analyst during the investigation |
| Daniel Remus Marante | Business Office Manager | Participated in exit interview and received report copy |
| Sheila Santos | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 98
Deficiencies: 0
Jan 18, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to deliver final findings for complaints received on 11/07/2022 regarding expired elevator permit, residents not allowed to pick their own pharmacy, and failure to provide transportation to medical appointments per admissions agreement.
Findings
The complaint alleging the facility's elevator permit was expired was deemed unsubstantiated due to lack of evidence. The complaint that residents were not allowed to pick their own pharmacy was found unfounded as residents could decline the facility's recommended pharmacy. The complaint that transportation to medical appointments was not provided was also found unfounded, with interviews confirming designated staff provide transportation and no missed appointments.
Complaint Details
The complaint investigation was unannounced and addressed three allegations: expired elevator permit (unsubstantiated), restriction on residents choosing their pharmacy (unfounded), and failure to provide transportation to medical appointments (unfounded). No deficiencies or citations were issued.
Report Facts
Facility capacity: 98
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Celine De Perio | Licensing Program Analyst | Conducted the complaint investigation and exit interview |
| Jennifer Thompson | Memory Care Director | Met with Licensing Program Analyst during investigation and exit interview |
| Stacie Anderson | Administrator | Facility administrator mentioned in investigation findings |
Inspection Report
Census: 36
Capacity: 98
Deficiencies: 0
Jul 12, 2022
Visit Reason
The visit was an unannounced Case Management visit related to Complaint 22-AS-20220531161434 and to review compliance with specific Title 22 regulations regarding medical and dental care, advanced directives, resident observation, and reporting requirements.
Findings
No deficiencies were issued during this Case Management visit. The Licensing Program Analyst reviewed regulations with the Executive Director, provided copies, and advised in-service training with documentation to be submitted by August 1, 2022.
Complaint Details
The visit was related to Complaint 22-AS-20220531161434; no deficiencies were found during the investigation.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacie Anderson | Executive Director | Met with Licensing Program Analyst during the visit and acknowledged receipt of regulations. |
| Patricia Velazquez | Licensing Program Analyst | Conducted the unannounced visit and reviewed regulations with the Executive Director. |
Inspection Report
Annual Inspection
Census: 35
Capacity: 98
Deficiencies: 1
May 13, 2022
Visit Reason
The inspection was an unannounced Required 1 Year inspection focusing on Infection Control at Pacifica Senior Living South Coast.
Findings
The facility was generally compliant with regulations, with adequate supplies, safety measures, and operational systems. However, a deficiency was found where hot water temperature in 3 out of 10 resident bathrooms exceeded the maximum allowed temperature, posing a health and safety risk.
Severity Breakdown
Level A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Hot water temperature exceeded 120 degrees Fahrenheit in 3 out of 10 resident bathrooms, posing an immediate health, safety, or personal rights risk to persons in care. | Level A |
Report Facts
Deficient bathrooms with hot water temperature exceeding 120 degrees F: 3
Resident rooms: 55
Licensed capacity: 98
Current census: 35
Hospice waiver capacity: 20
Bedridden resident capacity: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Velazquez | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stacie Anderson | Executive Director | Facility administrator met during inspection and involved in exit interview |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Annual Inspection
Census: 37
Capacity: 98
Deficiencies: 0
May 28, 2021
Visit Reason
This unannounced inspection was conducted for the purpose of an Annual Inspection to evaluate compliance with regulations and facility conditions.
Findings
The inspection found no health and safety issues; the facility was clean, organized, and compliant with COVID-19 related policies and regulations. No deficiencies were cited during this inspection.
Report Facts
Staff present: 13
Supply duration: 2
Supply duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stacie Anderson | Administrator | Facility Administrator met with Licensing Program Analyst during inspection |
| Sean Haddad | Licensing Program Analyst | Conducted the inspection and authored the report |
| Marina Stanic | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 98
Deficiencies: 3
Jan 25, 2021
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations including staff failing to seek timely medical treatment for a resident, inappropriate staff comments, blocking exits with furniture, neglect and lack of supervision resulting in a resident's fall and hip fracture, insufficient staffing, residents wandering out of the facility, failure to report an unusual incident, and medication mismanagement.
Findings
The Department substantiated allegations that staff failed to seek timely medical attention for a resident with injuries, staff made inappropriate comments, and exits were blocked with furniture. A civil penalty assessment is pending. Other allegations such as neglect causing the fall, insufficient staffing, residents wandering, failure to report incidents, and medication mismanagement were found unsubstantiated or unfounded.
Complaint Details
The complaint was substantiated for failure to seek timely medical treatment, inappropriate staff comments, and blocking exits. Neglect and lack of supervision causing a fall, insufficient staffing, residents wandering, failure to report incidents, and medication mismanagement were unsubstantiated or unfounded. A civil penalty of up to $10,000 is pending for physical abuse violation.
Severity Breakdown
Type A: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Memory care staff created barriers blocking the exit to the courtyard. | Type A |
| Incidental Medical and Dental Care Needs - The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including apparent life-threatening medical crisis. Staff failed to immediately telephone 911 when Resident #1 was found screaming with bleeding and hip pain. | Type A |
| Personal Rights - Residents shall be free from punishment, humiliation, intimidation, abuse, or other punitive actions. Staff #1 made inappropriate comments to residents. | Type A |
Report Facts
Facility capacity: 98
Census: 39
Civil penalty amount: 10000
Plan of Correction Due Date: Jan 26, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Reed | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Stacie Anderson | Administrator | Facility administrator met during investigation and exit interview |
| Maureen Salonga | Executive Director | Provided statements regarding medication allergy and facility operations |
| Staff #1 | Named in findings for making inappropriate comments to residents | |
| Luz Adams | Licensing Program Manager | Oversaw licensing program and signed report |
| Sheila Santos | Licensing Program Manager | Signed deficiency information section |
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