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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880572
Report Date: 03/29/2022
Date Signed: 03/29/2022 04:25:57 PM


Document Has Been Signed on 03/29/2022 04:25 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 LIVINGFACILITY NUMBER:
331880572
ADMINISTRATOR:TENG, JAMIEFACILITY TYPE:
740
ADDRESS:17085 BIRCH HILL ROADTELEPHONE:
(951) 850-1088
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 6DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jamie Teng, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA arrived at approximately 9:30 AM, signed in and utilized hand sanitizer. The LPA met with Administrator, Jamie Teng, and informed him of the purpose of her visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the facility and made observations pertaining to the facility's infection control measures. The LPA observed sufficient cleaning and disinfecting provisions and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan (Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report) in place which follows Community Care Licensing guidelines for when and how long to test staff and clients for COVID-19, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During today's visit the LPA observed the following violations: medication closet not locked and medication stored in kitchen pantry which was also unlocked. This poses a potential health and safety risk to the residents in care. A citation will be issued.

An exit interview to review this report was conducted with Teng and a copy was provided, along with the Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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 03/29/2022 04:25 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
FACILITY NUMBER: 331880572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
The following requirements shall apply to medications which are centrally stored: Medications shall be centrally stored under the following circumstances: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee failed to maintain medicines in a locked place that is not accessible to persons other than employees. The medication closet was not locked at time of inspection. In addition, the LPA observed medications belonging to staff stored in the kitchen pantry, which was not locked.
POC Due Date: 03/29/2022
Plan of Correction
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Medication closet was locked prior to the end of the inspection and medications in pantry were removed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
LIC809 (FAS) - (06/04)
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