331880572-10-5-2023-18-AS-JDHS-CWHTAN-20231011143350

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880572
Report Date: 10/05/2023
Date Signed: 10/05/2023 10:48:47 AM

Unsubstantiated

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-20230803114230

FACILITY NAME:	PACIFIC VISTA SENIOR LIVING		FACILITY NUMBER:	331880572
ADMINISTRATOR:	TENG, JAMIE		FACILITY TYPE:	740
ADDRESS:	17085 BIRCH HILL ROAD		TELEPHONE:	(951) 850-1088
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	6	CENSUS: 6	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Jamie Teng, Administrator		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to administer residents' medication as prescribed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Javina George made an unannounced visit to deliver findings for the allegations noted above. LPA met with Jamie Teng, Administrator and explained the purpose of the visit and the elements of the allegation noted above. The allegation was investigated, and 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. 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. However, the facility accepted residents without the residents being properly screened, as the evaluation for suitability for admission. Jamie stated that there was no admissions agreement completed, as R1 was only at the facility for a few hours when they began exhibiting aggressive behaviors, as they began to destroy their room. However, another interview conducted with facility staff revealed that R1 was at home for two (2) days and would yell at nighttime.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (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 2

Control Number 18-AS-20230803114230

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	FACILITY NUMBER: 331880572
	VISIT DATE: 10/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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 R1 did have a profile with them but no medication. LPA inquired as to why there would be a profile, but no medications. The pharmacy staff explained that “it could mean the medications were cancelled, transferred, or were never sent to the pharmacy”.

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 and the medication was sent over to the pharmacy. 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. A list of medications was not provided for LPA to review from the Pharmacy, due insufficient evidence 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 copy of this report, and appeal rights were reviewed and provided to Jamie Teng, Administrator.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (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: 2 of 2