374603496-9-19-2026-08-AS-JROO-DYF6Q6-20260930210014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603496
Report Date: 09/19/2026
Date Signed: 09/19/2026 12:24:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/21/2026 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20260121114736

FACILITY NAME:	PACIFIC BREEZE		FACILITY NUMBER:	374603496
ADMINISTRATOR:	PHOMTHAVONG, KEVIN		FACILITY TYPE:	740
ADDRESS:	137 PLAYA DEL REY AVE		TELEPHONE:	(760) 453-2722
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92058
CAPACITY:	6	CENSUS: 5	DATE:	09/19/2026
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Caregiver Reymundo Garvida		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff neglect resulted in a resident sustaining pressure injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Amy Rodgers, conducted a visit to deliver findings regarding the above mentioned allegation. LPA met with Licensee, Monica Siharath.

During the investigation, the facility was toured, records were reviewed, and interviews were conducted with staff, hospice personnel, and outside sources.

On January 21, 2026, Community Care Licensing (CCLD) received a complaint alleging that staff neglect resulted in resident #1 (R1) sustaining a pressure injury. R1’s medical records indicated R1 was non-ambulatory, dependent on staff for repositioning, and receiving hospice care at the time the pressure injury developed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20260121114736

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: PACIFIC BREEZE	FACILITY NUMBER: 374603496
	VISIT DATE: 09/19/2026

NARRATIVE

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(Continued from Lic9099)

Facility documentation showed R1 required total assistance with activities of daily living, including transfers, toileting, repositioning, and personal hygiene. Several staff interviews confirmed R1 needed frequent redirection and often resisted care due to cognitive decline

On the date the injury was discovered, staff documented a wound to R1’s sacral area and notified hospice. Hospice orders indicated wound care treatment was to be provided by the hospice agency, with the facility responsible for implementing supportive measures such as regular turning and monitoring for changes.

Department Interviews revealed staff were providing care and communicating changes to hospice; however, documentation of repositioning was inconsistent. Turning logs provided during the investigation did not consistently show two hour repositioning intervals, and time specific entries were missing on multiple dates. Further staff interviewed revealed that repositioning occurred as needed, but the lack of documentation made it difficult to verify frequency or consistency.

Department review of hospice records revealed R1 was at high risk for skin breakdown due to advanced age, immobility, poor intake, and terminal diagnosis. Department interviews with hospice personnel revealed the wound progressed despite interventions and was not uncommon given R1’s clinical condition. Department records reviewed confirmed R1 received ongoing wound care and had regular evaluations by the hospice nurse.

During the investigation, statements and records reviewed did not demonstrate that the pressure injury was more likely than not caused by staff neglect. Although documentation gaps were noted, evidence did not establish that the injury occurred due to lack of care or failure to follow medical directives. Based on the totality of information collected, the allegation is deemed unsubstantiated.

An exit interview was conducted with Licensee, Monica Siharath over the phone , and a copy of this report, along with Licensee Rights (LIC 9058), was provided to Caregiver Reymundo Garvida, whose signature below confirms receipt.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2026

LIC9099 (FAS) - (06/04)

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