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Inspection visit

complaint

Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

***AMENDED COMPLAINT INVESTIGATION FINDINGS*** Continued from LIC9099... the visit, a subsequent interview conducted with DRP on 02/12/2026, and an interview conducted with RP on 02/12/2026, both stated that Resident 1 (R1) moved in around 7pm at night on 10/20/25 and moved out between 1:00-2:00pm on 10/21/2025. RP stated R1 was not offered breakfast foods but rather was offered dinner foods the morning of 10/21/2025. RP also stated they changed R1 on their own but admitted not notifying facility staff that R1 needed to be changed or requesting assistance. RP stated that R1 did not incur any change of condition including compromised or decreased skin integrity as the result of their stay at the facility. RP further stated that they observed commodes and urinals full and smelled urine in the facility. Per interviews with DRP, facility staff check on each resident every couple of hours and this includes checking their briefs, commode, and urinals which are then changed and/or emptied as needed. During today's inspection, LPA completed a walk through of the facility, conducted interviews, and made observations. LPA found the facility to be clean, sanitary, and free from odors. LPA observed an empty bedside commode and urinal in two separate resident rooms. Based on interviews conducted with DRP and with residents R1, R2, and R3, residents are offered eggs, toast, pancakes, sausage, fruit, oatmeal, and similar foods for breakfast each day. Each stated they are checked on every couple hours where they are assisted with changing their briefs and urinals are emptied if indicated. LPA received conflicting information regarding food, incontinent care, and bedside care provided to R1 and other residents in care.. Based on interviews conducted, observations made, and records obtained, the listed allegations ARE UNSUBSTANTIATED . A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiencies cited. Exit interview conducted with DRP, whose signature on form confirms receipt of document(s).

Citations

2 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)(1)Type B

    Additional Personal Rights of Residents in Privately Operated Facilities 87468.2(a)(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance....This requirement is not met as evidenced by: Based on observations made and interviews conducted, Licensee did not ensure that R1 received a reasonable level of personal privacy while having their briefs changed. This poses a potential Health, Safety and/or Personal Rights risk to residents in care.

  • 87633(j)(1)Type A

    Hospice Care of Terminally Ill Residents 87633(j)(1) ...[F]acility staff, other than appropriately skilled health professionals, shall not perform any health care procedure that under law may only be performed by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not ensure that R1's morphine was administrered by an appropriately skilled professional. This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the February 17, 2026 inspection of PACIFIC GARDENS ON HAWKESBURY?

This was a complaint inspection of PACIFIC GARDENS ON HAWKESBURY on February 17, 2026. The inspection found no deficiencies and no citations were issued.

Were any citations issued to PACIFIC GARDENS ON HAWKESBURY on February 17, 2026?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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