Inspection visit

Follow-up on correctionsApril 25, 2024

SOUTH PACIFIC VILLALicense 3746044782 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to cite deficiencies which were identified during a separate Complaint Investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alfred Riosa. Interview of facility manager and outside sources, and records reviewed, aligned to show: Licensee met with the responsible person (RP) for Resident #1 (R1) on 07/18/2022 for a care conference meeting. During this meeting, Licensee personally served RP with an eviction letter titled, “30 Days Notice.” CCLD reviewed a copy of this letter. Although the Department determined that the basis for R1’s eviction was valid, the contents of Licensee’s eviction letter did not meet all regulatory requirements. Licensee did not include in the letter “a statement informing residents of their right to file a complaint with the licensing agency” and the name, address, and telephone number of the local licensing office and the State Long Term Care Ombudsman office, as was required. Licensee did not include in the letter the required disclosure statement described in California Health and Safety Code Section 1569.683(a)(4), which reads: "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Interviews showed that R1 voluntarily moved out of the facility prior to the expiration of 30-day notice period. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (see the LIC 809-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Riosa, to whom a copy of this report, the LIC 809-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Citations

4 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87468.2(a)(3)Type B
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents…shall have all of the following personal rights: (3)…Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.” This requirement was not met, as evidenced by: Based on records and interview, Licensee did not ensure that 2 of 6 residents (R1 and R2) were free from interference and retaliation in exercising their rights. This posed a potential personal rights risk to persons in care.
87224(d)(1)(C)Type B
87224 Eviction Procedures: “(d)(1) The notice to quit shall include the following information: (C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office.” Based on records and interview, for 1 of 6 residents (R1), Licensee did not ensure that their notice to quit included a statement informing them of their right to file a complaint with the licensing agency, including the name address and telephone number of the local licensing office and the State Long Term Care Ombudsman office. This posed a potential personal rights risk to persons in care.
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87224(d)(1)(D)Type B
87224 Eviction Procedures: “(d)(1) The notice to quit shall include the following information: (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Based on records and interview, for 1 of 6 residents (R1), Licensee did not ensure that their notice to quit included the exact statement that is specified in California Health and Safety Code Section 1569.683(a)(4). This posed a potential personal rights risk to persons in care.
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87465(h)(4)Type B
87465 Incidental Medical and Dental Care: “(h)(4) All centrally stored medications shall be…maintained in compliance with state and federal laws.” This requirement was not met, as evidenced by: Based on interview and LPA observation, Licensee did not ensure that all centrally stored medications were maintained in compliance with state and/or federal laws. This posed a potential health and safety risk to 2 of 6 residents (R1 and R2) in care.

FAQ · About this visit

Common questions about this visit

What happened during the April 25, 2024 inspection of SOUTH PACIFIC VILLA?

This was a other inspection of SOUTH PACIFIC VILLA on April 25, 2024. 2 citations were issued: 2 Type B.

Were any citations issued to SOUTH PACIFIC VILLA on April 25, 2024?

Yes, 2 citations were issued (0 Type A, 2 Type B). The first citation was for: "87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents…shall have all of the f..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

Follow-up on corrections·April 25, 2024