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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880572
Report Date: 04/02/2024
Date Signed: 04/02/2024 12:13:38 PM


Document Has Been Signed on 04/02/2024 12:13 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 LIVINGFACILITY NUMBER:
331880572
ADMINISTRATOR:TENG, JAMIEFACILITY TYPE:
740
ADDRESS:17085 BIRCH HILL ROADTELEPHONE:
(951) 850-1088
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 6DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Evangeline Dela Rosa, Caregiver TIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility for the purpose of conducting a 1 year required visit/annual inspection. LPA was greeted and granted entry by Caregiver Evangeline Dela Rosa, where LPA explained the purpose of the visit. At the time of the visit there was three staff and six residents present. Staff #1 (S1) was observed to not have obtained proper fingerprint clearance, nor to be associated to the facility, and was escorted off the premises, an immediate $500 civil penalty is being assessed. The Administrator Jamie Teng, was unavailable to come to the facility as they were out conducting resident interviews but was available via telephone.

LPA conducted a tour of the interior and exterior of the facility. The facility was observed to be clean and clutter free. LPA observed for there to be several games, available for the residents to play and interact with one another. The medications were observed to be locked and inaccessible to residents in care. LPA did not observe an adequate supply of hygiene items, or personal protective equipment (PPE).

There is a covered patio, with plenty of seating available. LPA observed for there to be two (2) added on staff bedrooms inside the garage. Staff on grounds denied being live in caregivers, and that the rooms are used to take breaks. The facility needs to be updated and submitted to the regional office.

Food service: the facility was observed to have a 2 day supply of perishable and a 7 day supply of non perishable food items. LPA observed for the facility to have expired food items such as oatmeal, cream of wheat, box mashed potatoes, canned goods, corn bread mix dating back to May 2021. The expired food items were discarded at the time of LPAs visit, therefore a citation was not issued.

The hot water was tested in all three resident bathrooms and was found to be within regulatory limits, measuring 106.5-115.3 degrees Fahrenheit. It is unknown as to when the last emergency disaster drill was conducted as the logs were unavailable for LPA to review. The facility does not have an active mitigation plan on file that was submitted to the regional office, in addition the smoke detectors were not operable, as they
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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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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
FACILITY NUMBER: 331880572
VISIT DATE: 04/02/2024
NARRATIVE
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could not be tested, LPA observed for the cover to be open with no battery inside. The facility does not have a carbon monoxide detector, an immediate $500 civil penalty is being assessed.

LPA was unable to review both staff and resident files as per Jamie Teng, Administrator, the facility has gone all electronic and he had the documents with him. Jamie stated that he would send the docs, however they were not received during LPAs inspection.

The facility was observed to have the required postings, the emergency disaster plan was observed to not have been updated since 05/01/2018.

The following is to to be submitted to the regional office:
-LIC808 Mitigation plan, LPA emailed PIN 20-48-ASC to the Administrator for review
-Updated facility sketch
-Emergency disaster plan (LIC610E)
-(3) Staff files requested
-(3) Resident files requested
-Image/video of additional hygiene supplies and personal protective equipment (PPE)

As a result of today's inspection a meeting will be held at the regional office, in order to discuss the facility getting into compliance.

Based on today's inspection deficiencies are being issued/cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8) on the attached 809D.

An exit interview was conducted and a copy of this report, appeal rights, 809D, LIC421BG, LIC421IM and LIC 9098 Proof of Corrections for was reviewed and provided to Evangeline Dela Rosa.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 04/02/2024 12:13 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
FACILITY NUMBER: 331880572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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The licensee agrees to purchase a carbn monoxide detector, and install it at the facility. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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The licensee agrees to have at minimum 3 staff enroll in CPR certification course. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 04/02/2024 12:13 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
FACILITY NUMBER: 331880572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

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 in 1 out of 1 time as S1 does not have proper fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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The Licensee agrees to have have S1 obtain proper fingerprint clearance and associate them to the facility. S1 will not work on grounds until proper clearance has been obtained POC is to be submitted to the department by 5pm on the due date indicated.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above in 1 out o 1 time which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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The licensee agrees to conduct an emergency disaster drill, proof of POC is to be submitted to the department by 5pm on the due date indicated.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 04/02/2024 12:13 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
FACILITY NUMBER: 331880572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

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 in 1 out of 1 time which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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The licensee agrees to complete a mitigation plan (LIC808) , proof of POC is to be submitted to the department by 5pm on the due date indicated.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

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 in 6 out of 6 times as LPA requested to review a total of 6 files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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The licensee agrees to have both resident and staff files available at the facility to be reviewed. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 04/02/2024 12:13 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
FACILITY NUMBER: 331880572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(1)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident.

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 in [1 out of 1 times which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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The licensee agrees to complete a resident roster, proof of POC is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6