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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880558
Report Date: 10/05/2023
Date Signed: 10/05/2023 10:22:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/03/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230803125541
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
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Jamie Teng, Administrator TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff are not properly trained to meet resident needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the aleegation noted above. LPA met with Administrator Jamie Teng and explained the purpose of the visit. The allegation was investigated. The investigation consisted of observations, interviews and records review.

It was alleged that on or around 8/3/23, Resident #1 (R1) was “acting erratically” which prompted 9-11 being called out to the facility. It was also alleged that the facility staff was unable to provide any information about R1’s health conditions, and nor could any of the staff could provide any answers to the questions that were asked pertaining to R1. Per an interview with R1’s responsible party due to R1 and their current state exhibited over the past month agreed that the home was not appropriate and did not want R1 to stay at the facility. LPA conducted a complaint visit on 8/8/23 and there was no training information available as the facility was reportedly converting to electronic files. LPA requested the training documentation. The training checklist were received and reviewed and the checklist for Staff #1 is altered.


Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20230803125541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Their form has white out with their name typed over it. It was further observed that the hours and signatures are the exact same. Per interviews with facility staff, the training received was from a personal experience from a family member and from working at another residential care for the elderly facility, prior to working at the facility.

In addition per the Administrator Jamie Teng “the training dates are unknown as the training was completed prior to both Staff #1 (S1) and Staff #2 (S2) being hired”. Based on interviews the allegation of Staff are not properly trained to meet resident needs is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and copy of this report, 9099D, and appeal rights were reviewed and provided to Jamie Teng, Administrator.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/03/2023 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230803125541

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
UNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Jamie Teng, Administrator TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff did not provide resident with medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the deliver findings for the aleegation noted above. LPA met with Administrator Jamie Teng and explained the purpose of the visit. The allegation was investigated. The investigation consisted of observations, interviews and records review.

Regarding the allegation of staff failed to administer resident’ medication as prescribed. Resident #1 (R1) was admitted to the facility on or around August 3, 2023. Administrato Jamie stated that there was no admissions agreement completed, as “R1 was incorrectly placed in the facility by the Skilled Nursing Facility (SNF), and left the facility immediately”.

Per an interview with SNF staff revealed that R1 was discharged, with a prescription, that was sent to a local pharmacy. In addition, per SNF staff when medication is sent to the pharmacy, the medication will be delivered the same day if not the next day. Per an interview with the local pharmacy staff revealed that
***Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20230803125541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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R1 did not have a profile with medications on file with them. During the initial complaint visit conducted on 8/8/23, LPA did not observe a facility file nor documents, to confirm which medications R1 was prescribed. However, it was confirmed that R1 was discharged from the SNF to the facility, but no confirmation that R1’s medication was sent over to the pharmacy.

Additionally, there was no other explanation provided from the Administrator Jamie, other than “no R1 was not given any medication at the facility as they were not a resident". Therefore, the allegation of staff failed to administer residents medication as prescribed is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted and a copy of this report, and appeal rights were 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20230803125541
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87411(a)
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87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering and
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The licensee agrees to retrain both S1 and S2 with the training listed on the staff training checklist. Proof of completed POC is due by 5pm on 10/20/23.
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maintenance of buildings, equipment grounds... This requirement is not met as evidenced by: The licensee failed to ensure staff were properly trained to provide care and supervision to R1, 2 out of 2 times. This poses a potential health, safety and personal rights risk to persons in care.
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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) 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5