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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880558
Report Date: 08/04/2023
Date Signed: 08/04/2023 05:14:43 PM


Document Has Been Signed on 08/04/2023 05:14 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: 5DATE:
08/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Staff, Doming Altoba TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a visit to the facility for an unrelated matter and found deficiencies in the process. This report is to document those deficiencies. LPA met with staff, Dominga Altoba who was informed of the purpose of the visit.

It was found through interview with Licensee that Resident #1 (R1) had been diagnosed with an infectious disease under the Title 22 Prohibited Conditions. R1's responsible party was contacted who stated they were informed by licensee that they could not return to the facility. Licensee confirmed this and stated they had provided a list of placement's for R1 and had gone on to accept another resident in R1's place. Licensee stated they had not issued the family with an eviction notice as the family had agreed to move R1. Licensee also stated they could get Resident #2 (R2) to move within a couple days from the facility as they seemed to be a "reasonable" person. Licensee was unaware of the fact that they needed an eviction notice. During today's visit PA was informed by staff that R3 had been discharged after living at the facility for (2) days. LPA also observed R1 was still not back at the facility. Therefore, based on the above the facility failed to provide R1 and R3 with an eviction notice when warranted.

Deficiency was cited under California Code of Regulations Title 22 on an LIC809-D. Plan of correction was unable to be made with licensee over the phone as licensee acted in unprofessional manner. Licensee will be contacted for an office meeting. An exit interview was conducted with Staff Dominga Altoba where this report along with LIC809-D page and appeal rights were reviewed and provided to them. Staff refused to sign the report.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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Document Has Been Signed on 08/04/2023 05:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 2
FACILITY NUMBER: 331880558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
87224(a)(4)

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(a) The licensee may evict a resident for one or more of the reasons listed...(30) days written notice to the resident is required...(4)...it is determined that the resident has a need not previously identified...
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LPA was unable to get a plan of correction as the licensee acted in an unprofessional manner over the phone.
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This requirment is not met as evidenced by: The licensee failed to serve an eviction notice to R1. This poses a potential health, saftey or personal rights risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
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