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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880572
Report Date: 10/04/2022
Date Signed: 10/04/2022 02:28:42 PM


Document Has Been Signed on 10/04/2022 02:28 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:
10/04/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Staff Evangelica Dela RosaTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to issues deficiencies observed. LPA met with staff Evangelica Dela Rosa who was informed of the purpose of the visit on 10/4/2022.

LPA found through interview with Licensee that Staff #1 (S1) was a candidate for hire at the facility. Licensee stated that (S1) had not been fingerprinted and had not been at the facility. LPA interviewed a staff member who stated that S1 had been working at the facility in a resident’s room. LPA interviewed resident mentioned by staff, who stated S1 had been working and assisting her at the facility for the week of 09/11/2022 to 09/17/2022. LPA reviewed the Guardian roster for the facility and found that S1 was not listed, Licensee confirmed that he had not yet associated, hired, or fingerprinted this staff member.

Therefore, based on staff and resident interviews, and review of staffing records it was found that a civil penalty will be issued for uncleared staff member who had resident contact. LPA will issue a civil penalty for $100 per day per person to the maximum of 5 days, resulting in $500 civil penalty. This will be documented on LIC421BG form along with LIC809-D and plan of correction.

An exit interview was conducted where this report, LIC809-D, appeal rights, and LIC421BG were review with…Reports were provided to Evangelica Dela Rosa

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
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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Document Has Been Signed on 10/04/2022 02:28 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: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
Section Cited

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"87355 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department ..."
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This requirment was not met as evidenced by:
Staff and resident interview confiming employee is working at the facility and is not fingerprinted. This is an immediate personal rights, health or safety risk.
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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: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2022
LIC809 (FAS) - (06/04)
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