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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880572
Report Date: 06/10/2022
Date Signed: 06/10/2022 10:23:36 PM


Document Has Been Signed on 06/10/2022 10:23 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: 5DATE:
06/10/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
06:45 PM
MET WITH:Jamie Teng, LicenseeTIME COMPLETED:
08:45 PM
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Licensing Program Manager (LPM) Deborah Mullen conducted an unannounced visit for the purpose of a health and safety inspection. LPM met with Jamie Teng, Licensee and was granted entrance into the facility. LPM interviewed Licensee, Resident 1 (R1) and Staff 1 (S1). LPM did not observe any immediate health and safety concerns at the time of the visits. LPM discussed with Mr. Teng the requirement to assist resident and provide meals as well as provide assistance with emptying residents commode. mr. Teng confirmed that he will ensure resident is provided meals and that the commode is emptied for the resident.

LPM conducted an exit interview with Mr. Teng. This report was reviewed with Mr. Teng and a copy of report was provided to him.


Note: A hand-typed version of this report was provided to licensee. The original signature acknowledging receipt of report is on file.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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