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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880572
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:16:47 PM


Document Has Been Signed on 10/06/2022 01:16 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:
10/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Licensee, Jamie TengTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility for a case management visit. LPA met with Licensee, Jamie Teng, who was informed of the purpose of the visit.

The LPA had requested a written record of care for Resident 1 (R1) on October 4, 2022. The licensee informed the LPA on October 4, 2022 they did not have a written record of care for R1. During today’s visit, the LPA reviewed R1’s resident file and found it did not contain a written record of care. A deficiency was cited.

The review of R1’s file also revealed the admission agreement is not signed by R1. R1 was admitted to the facility on May 10, 2022. A completed admission agreement is required within 7 days. A deficiency was cited.

An exit interview was conducted where a copy of this report along with LIC809-D page, and appeal rights were reviewed and provided to Licensee, Jamie Teng
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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 2


Document Has Been Signed on 10/06/2022 01:16 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: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
Section Cited

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87507 Admission Agreements (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. This requirement was not met as evidenced by:
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Based on interview and records review it was found that the licensee did not ensure the admission agreement signed within the required time frame. This poses a potential health, safety, or personal rights risk for residents in care.
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Type B
11/04/2022
Section Cited

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87467 Resident Participation in Decisionmaking (a)... within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative... and any other appropriate parties, to prepare a written record of the care the resident... regarding the services provided at the facility.
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This requirement was not met as evidenced by: Based on interview and records review it was found that the licensee did not ensure a written record of care was completed. This poses a potential health, safety, or personal rights risk for residents in care.
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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: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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