331880572-6-3-2022-18-AS-TDAN-D3RTDU-20240327143854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880572
Report Date: 06/03/2022
Date Signed: 06/03/2022 03:16:33 PM

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
05/27/2022 and conducted by Evaluator Janira Arreola

COMPLAINT CONTROL NUMBER: 18-AS-20220527135858

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:	06/03/2022
		UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Administrator - Jaime Teng		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Facility is issuing an unlawful eviction notice to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Janira Arreola arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation. LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Administrator Jaime Teng. Below is a summary of the complaint investigation findings:

Regarding allegation of an unlawful eviction notice: LPA Arreola interviewed staff and resident regarding the allegation. LPA reviewed proof of the eviction notice that was issues to the resident, and the admissions agreement that was signed by Administrator Jaime Teng. LPA reviewed these documents along with text messages and e-mail conversations. The evicition notice does not cite any reason included in Title 22 Section 87224(a)(1) through (5).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220527135858

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/13/2022 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)	1 2 3 4 5 6 7	Licensee will acknowledge that this eviction notice is invalid and unlawful. Licensee shall not imporerly evict any other resident at their facility.
	8 9 10 11 12 13 14	LPA reviewed 30-day eviction given to resident and observed that the eviction did not cite a reasoing detailed in Title 22.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220527135858

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: 06/03/2022

NARRATIVE

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Therefore, based on interviews and file review conducted, the allegation of "Facility is issuing an unlawful eviction notice to resident" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Arreola, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Administrator, Jaime Teng.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022

LIC9099 (FAS) - (06/04)

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