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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880572
Report Date: 06/03/2022
Date Signed: 06/03/2022 03:18:14 PM


Document Has Been Signed on 06/03/2022 03:18 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:
06/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:24 PM
MET WITH:Administrator- Jaime TengTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola went to the facility for an unannounced visit pertaining to a complaint investigation 18-AS-20220527135858. During the investigation LPA and Administrator Jaime teng, observed the following deficiencies:

Upon doing record review, LPA found that Eviction notice that had been issued by the facility had not been reported to the department. This goes against Title 22 regulation on Eviction Procedures. Facility will receive a type B deficiency for this, and will be documented on an LIC809-D.

Upon reviewing the facility roster LPA found that S1 was not associated to the facility and did not posess a background clearance. This is a violation of the zero tolerance regulation found in Title 22. Facility will receive a Type A citation for this as well as a civil penalty of $500. This will be documented on a LIC809-D.

An exit interview was conducted and a copy of this report, appeal rights, and 809-D pages were reviewed and provided to facility Administrator, Jaime Teng.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 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.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 06/03/2022 03:18 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: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2022
Section Cited

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87224 Eviction Procedures(f) A written report of any eviction shall be sent to the licensing agency within five (5) days.
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Based on record review and interview, Licensee did not submit the 30-day evicit to the department.
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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 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
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/03/2022 03:18 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: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
80019 Criminal Record Clearance (1) Obtain a California clearance or a criminal record exemption as required by the Department
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LPA conducted record review and found that S1 was not associated and did not possess a background clerance.
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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: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 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
LIC809 (FAS) - (06/04)
Page: 3 of 3