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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880558
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:46:13 PM


Document Has Been Signed on 11/09/2022 02:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:PACIFIC VISTA SENIOR LIVING 2FACILITY NUMBER:
331880558
ADMINISTRATOR:TENG, JAMIEFACILITY TYPE:
740
ADDRESS:17081 BIRCH HILL RDTELEPHONE:
(951) 850-1088
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator Jaime TengTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA), Janira Arreola made an unannounced visit to the facility on 11/9/2022 at 1:20 p.m. to conduct an annual inspection focused on infection control. LPA was granted entry and met with Licensee/ Administrator, Jaime Teng, who was informed of the purpose of the visit. At the time of visit there was (3) staff and (5) residents present. The facility currently has zero positive or suspected Covid-19 cases.

During today's visit, LPA toured the facility interior and exterior. LPA observed Covid-19 postings and a single entry point was designated where symptoms screenings and temperature checks occur daily for all visitors, residents, and staff. The facility had a plan in place to clean and disinfect the high touch surfaces. LPA observed the resident restrooms which had the adequate amount of hand hygiene supplies (soap, hand sanitizer, paper towels). LPA observed the resident bedrooms where the residents would be isolating. There is a plan in place to monitor and attend to those in the isolation rooms.

LPA observed the facility did not have a 30-day supply of PPE equipment. This will be documented on a technical advisory note, and Administrator was able to place more PPE equipment at the facility by the end of the visit. The facility also has a designated infection control lead and a plan in place report covid positive cases. LPA reviewed the facilities infection control plan for COVID. LPA will document technical advisory note for facility to make infection control plan for Monkey Pox and submit to LPA by the end of the day 11/9/2022.

LAP noticed the kitchen drawer where the knifes are being kept had a broken safety latch. The administrator was able to place the knifes in a different drawer immediately, while this is repaired. This will be documented on a technical advisory note. LPA will document technical advisory note for updated LIC9020 to ensure all contact information for residents has been updated. The administrator was able to update this by the end of the visit.

No deficiencies were issued at the time of the visit. An exit interview was conducted where this report was reviewed and provided to Administrator Jaime Teng.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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