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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880558
Report Date: 11/20/2023
Date Signed: 11/20/2023 01:32:18 PM


Document Has Been Signed on 11/20/2023 01:32 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 2FACILITY NUMBER:
331880558
ADMINISTRATOR:TENG, JAMIEFACILITY TYPE:
740
ADDRESS:17081 BIRCH HILL RDTELEPHONE:
(951) 850-1088
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 4DATE:
11/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Licensee, Jaime TengTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Jaime Teng, who was informed of the purpose of the visit. At time of visit there were (4) residents and one (3) staff present.

The facility is a one story home with four (4) bedrooms and (2) bathrooms. No pools or fire arms are kept at the facility. The facility serves resident ages of 60 years and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: LPA observed the hand washing stations and hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility.

Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 106.8F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment. LPA observed the refrigerator in the facility kitchen to be taken out of its cavity with a tool box besides it. LPA was informed by staff that the freezer was currently not working. Technical advisory note was documented with licensee plan on repair and plan to ensure residents have required food available. LPA observed the food supply for the facility and observed it was within the required amounts.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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: 11/20/2023
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Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. The administrator has proof of submitting a recertification for Administrator certificate to the department. Resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in living room cabinet. LPA reviewed client medications for residents and observed two (2) resident medications that were being kept in weekly pill boxes. This poses a potential risk for medication errors. LPA also found medication for one (1) resident was being stored on residents bedside table unlocked. This poses a potential risk for other residents to have access to the medication. These deficiencies were cited along and plan of correction was created with licensee.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Technical advisory note was documented for licensee to updated their LIC610D to the meet department requirements. Licensee was given direction on where to find this information. LPA reviewed documentation showing last fire drill conducted 8/28/23. The licensee agreed to hold another drill by the end of the month. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report, deficiency pages, and appeal rights were provided to Licensee, Jaime Teng.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/20/2023 01:32 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: 11/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above with 1 resident was being stored unlocked on the residents bedside table. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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The licensee stated they would show proof to the LPA that R1's medication is being kept locked and inaccessible to other residents. This is due by the POC due date.
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with medication that was being kept in weekly pill boxed for two (2) residents. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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The licensee stated they would send a self certified statement signed by himself and staff that medication procedures will change to comply with the regulation cited above. This is due by the POC due date.
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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5