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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202783
Report Date: 06/19/2026
Date Signed: 06/19/2026 11:08:29 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/24/2026 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20260224170312
FACILITY NAME:CAMDEN SENIOR LIVINGFACILITY NUMBER:
435202783
ADMINISTRATOR:ALLAN JAY PACISFACILITY TYPE:
740
ADDRESS:1607 INGLIS LANETELEPHONE:
(408) 677-3111
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 6DATE:
06/19/2026
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Administrator, Allan Jay PacisTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility staff did not address fall risk prevention when resident had a fall at the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Administrator, Allan Jay Pacis and stated the purpose of today’s visit.

On 02/24/2026, the Department received a complaint with the above allegations. On 02/25/2026, the Department conducted an initial investigation at the facility. It was alleged that the resident (R1) fell on 02/19/2026 and 02/21/2026 and the facility staff did not address fall risk prevention for R1.

On 02/25/2026, LPA Rai interviewed 3 staff (S1-S3). Three out of three staff stated there has been a change of condition for R1, wherein R1 started falling at the facility in February 2026. They stated R1 has been restless at night, and not sleeping throughout the night, which has increased the number of falls. They stated R1 has had 3 falls on 02/19/2026, 02/21/2026 and 02/22/2026.

Continuation on LIC 9099-C, Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20260224170312
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CAMDEN SENIOR LIVING
FACILITY NUMBER: 435202783
VISIT DATE: 06/19/2026
NARRATIVE
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Page 2 of 2.
Three staff stated the staff called R1's doctor after the first fall and the other 2 falls resulted in R1 being transported to the hospital. Three out of three staff stated there are fall prevention measures in place which were established when R1 moved into the facility. All three staff stated R1's fall prevention which is also documented on R1's Appraisal/Needs and Services Plan are increasing supervision by staff, at least every 2 hour status check and checking on R1 whenever the facility staff pass R1’s room in the hallway, placing a commode in resident’s room to increase R1's independence and safety, using a bed alarm as a secondary alert to notify staff and encouraging resident to come out to the common areas to interact with other residents. They stated R1’s authorized representative is working with hospital staff for physician to assess the resident since R1 had 3 falls in 4 days and no new orders have been given to the facility staff.
Based on review of R1’s Appraisal/Needs and Services Plan of 12/08/2024, 03/27/2025 and 02/05/2026, facility staff documented R1’s objective and plan for risk of fall which was signed by both facility’s representatives and resident’s authorized representatives. The plan addressed fall risk prevention which included providing a safe, barrier-free environment that encourages independent activity, keeping care area uncluttered, keeping needed items within reach (eg. call light, personal items), promoting regular intentional rounding to assess for position change, pain assessment, personal needs, set/activate auditory alerts, ensure equipment is functioning appropriately, providing adaptive/assistive devices(eg. commode, raised toilet seat, cane, walker), providing appropriate bed/furniture choice for diagnosis/activity, utilize bed rails appropriately, providing stabile/heightened seating and maintaining bed in lowest position with brakes locked.
Based on review of R1's Incident Reports, on 02/19/2026, R1 had a fall and facility staff contacted R1’s doctor after resident did not complain of any pain. On 02/21/2026, R1 had a fall and facility staff called Kaiser nurse hotline which advised staff to call 911. R1 was taken to the hospital and returned the same day in the evening. On 02/22/2026, R1 had a fall and facility staff called Kaiser nurse hotline which advised staff to call 911 to transport R1 to the hospital.

Based on the interviews conducted with staff and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Allan Jay Pacis and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2