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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880558
Report Date: 10/05/2023
Date Signed: 10/05/2023 10:34:52 AM


Document Has Been Signed on 10/05/2023 10:34 AM - 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:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Jaie Teng, AdministratorTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit as LPA was delivering findings for complaint control # 18-AS-20230803125541 and observed the following deficiencies.

The facility admitted (accepted responsibility) for Resident #1 (R1) on or around August 3, 2023. Per interviews with Administrator Jamie Teng, there is a contract or agreement with a local skilled nursing facility (SNF) to discharge residents from the SNF to the facility. Due to this contract or agreement, the facility is accepting residents without properly screening them, as well as not completing the evaluation of suitability for admission. The evaluation consist of: (1) Conduct an interview with the applicant and his responsible person. (2) Perform a pre-admission appraisal. (3) Obtain and evaluate a recent medical assessment). Per an interview with Administrator Jamie, the LIC 602 (Physician's report) was requested but was never sent over.

As a result of the facility not properly screening new residents. R1 was admitted to the facility and began exhibiting erratic behaviors by trying to hurt thyself. As a result the facility had to contact 9-11 to assist, and have R1 removed without returning to the facility. Further interviews conducted with R1's responsible party who deemed the facility was not suitable for R1 and they should have not been sent there due to their current mental state that R1 had been exhibiting for the past a couple of months.

Additionally, LPA observed that when LPA requested the staff files for review from the Administrator Jamie Teng. Jamie stated that the facility was in the process of converting to electronic files. Jamie verbally provided Staff #1 (S1) and Staff #2 (S2) hire dates. In addition to Administrator Jamie provided a copy of the staff training checklist that was the exact same, however S2’s name is written over S1’s name that had been covered with white out. The hours are off center and the exact same hand writing. Interviews with S1 and S2 stated that they both received training prior to working at the facility.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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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
VISIT DATE: 10/05/2023
NARRATIVE
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Not only did the Administrator make false claims but provided false training documents and is being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8) on the attached 809D.

An exit interview was conducted and a copy of this report, and appeal rights were reviewed and provided to Administrator Jamie Teng.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/05/2023 10:34 AM - 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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
87456(a)(1-3)

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87456 Evaluation of Suitability for Admission (a)(1-3) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (1) Conduct an interview with the applicant and his responsible person. (2) Perform a pre-
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The licensee agrees to submit a personal statement self certifying that any new residents moving forward the facility will conduct an evaulation of suitability.
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admission appraisal. (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: The licensee failed to conduct an evaluation for R1, 1 time. This posed a potential health, safety and personal rights risk to persons in care.


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Type B
10/20/2023
Section Cited
CCR87207

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87207 False Claims No licensee, officer or employee of a license shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
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The licensee agrees to make a personal statement of understanding about the importance of providing true and accurate information to the department, The statement is to include the potential risks and consequences of providing
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2 out of 2 times the licensee stated that their staff received training upon hire. This poses a potential health, safety, and personal rights risk to persons in care.
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misleading/false claims, or statements. Proof is to be submitted to the department by 5pm on the due date indicated.
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) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3