331880558-11-13-2024-18-AS-APEZ-DAYTCY-20241113133732

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880558
Report Date: 11/13/2024
Date Signed: 11/13/2024 01:37:47 PM

Document Has Been Signed on 11/13/2024 01:37 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PACIFIC VISTA SENIOR LIVING 2		FACILITY NUMBER:	331880558
ADMINISTRATOR/ DIRECTOR:	TENG, JAMIE		FACILITY TYPE:	740
ADDRESS:	17081 BIRCH HILL RD		TELEPHONE:	(951) 398-7160
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Jamie Tang		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE

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Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Administrator, Jamie Tang. The LPA informed the Administrator of the purpose for the visit. The inspection included the following:

The facility consists of four (4) resident bedrooms, two (2) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry area, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator, no weapons are stored in the home. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. The home is maintained at a comfortable temperature for the clients. Water temperature measured 103.4 degrees F. Lighting in the kitchen and one of the bedrooms had a broken dimmer switch that made it difficult to turn on the lights and will need to be repaired. A citation will be cited. The home was kept clean and free of any odors.

LPA began review of client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

LPA began review of employee records- Three (3) records were reviewed. LPA reviewed employee records for first aid certification, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 07/30/2025. LPA observed the criminal record clearance or an exemption records was not kept with personnel files. Administrator stated they believed having Guardian clearance was sufficient enough. A technical assistance will be issued for the fingerprint clearance not accessible within a reasonable time.

Jazmond D Harris	TELEPHONE: (951) 529-2439
Armando Perez	TELEPHONE: (951) 248-2222
	DATE: 11/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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 11/13/2024 01:37 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
RIVERSIDE ASC, 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation], the licensee did not comply with the section cited above in 2 out locations with broken dimmer light switches which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Administrator will provide proof to LPA of replaced dimmer light switches to the kitchen and the end bedroom.

Section Cited

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of 2 bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Administrator will provide LPA with proof of training with staff on a refresher to storing chemicals in locked cabinet only.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Jazmond D Harris	TELEPHONE: (951) 529-2439
Armando Perez	TELEPHONE: (951) 248-2222
	DATE: 11/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/13/2024 01:37 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
RIVERSIDE ASC, 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: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one out of one expired fire extinguisher which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/14/2024
	Plan of Correction
1 2 3 4	Administrator will email photo of the receipt and the new fire extinguisher.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Jazmond D Harris	TELEPHONE: (951) 529-2439
Armando Perez	TELEPHONE: (951) 248-2222
	DATE: 11/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFIC VISTA SENIOR LIVING 2	FACILITY NUMBER: 331880558
	VISIT DATE: 11/13/2024

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LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals in the living room and and for sharps in the kitchen. LPA observed cleaning chemicals under a bathroom sink consisting of floor liquid cleaner and sprays. A citation will be cited.

Medication- are centrally stored. There is a locked closet in the living room allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. LPA observed Fire extinguisher to be expired and needing service. A citation will be cited. The facility is conducting emergency disaster/fire drills quarterly; last done on 10/01/2024.

Based on the information received during this visit today in the areas reviewed, there are deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. A plan of correction has been discussed and agreed upon with Administrator.

An exit interview was conducted, and this report was discussed and provided to Administrator, Jaime Teng.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 529-2439
LICENSING EVALUATOR NAME: Armando Perez	TELEPHONE: (951) 248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

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