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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880572
Report Date: 10/06/2022
Date Signed: 10/06/2022 01:19:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2022 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220623154318
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
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee/Administrator Jaime TengTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff failed to provide food
Staff failed to provide toileting assistance
Staff failed to clean the resident's room
Staff failed to administer medications to resident
Staff are retaliating against the resident
Staff are abusing resident with threats and calling resident bad names
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) Janira Arreola, made an unannounced visit to the facility in order to deliver investigation findings on the above allegations. LPA met with Licensee, Jaime Teng who was informed of the purpose of the visit. During the investigation, interviews were conducted and records were reviewed.

It was alleged that on June 10, 2022, staff did not assist Resident 1 (R1) in getting food. Interviews revealed R1 last had staff communicate with them at 9pm on June 9, 2022. R1 made attempts to communicate with staff in obtaining food but staff failed to respond. Attempts were made starting at 8am on June 10, 2022. Interviews revealed that R1 made attempts to several phone numbers including the facility’s landline. R1’s responsible party arrived at approximately 1pm to assist R1 since they had still not been provided food. Interviews were conducted with staff identified as being on duty on June 10, 2022. Staff interviews revealed S2 acknowledged they did not provide any assistance to R1 during their shift. S1 refused to answer interview questions. Licensee interview revealed that licensee was unable to assist due to illness and fraturced communication with the resident. Therefore, based on interviews conducted and records reviewed, the allegation is substantiated.
***CONTINUED ON LIC9099-C PAGES***
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2022 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220623154318

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
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee, Jaime TengTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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 Licensee violated Resident Admission Agreement
INVESTIGATION FINDINGS:
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Licensing Program Anayst (LPA) Janira Arreola, made an unannounced visit to the facility in order to deliver findings on the allegations listed above. LPA met with Licensee, Jaime Teng who was informed of the purpose of the visit.

It was alleged the facility was not abiding by Resident 1 (R1)’s admission agreement. A copy of the admission agreement from the facility and R1 was obtained. Neither copy was signed by all relevant parties, to include a facility representative and the resident. The admission agreements also differed in that R1’s copy had an addendum page that the facility’s copy provided did not have this page. Emails were also provided during the investigation indicating that an addendum could be added however, the terms of the addendum were not outlined in the email. Interviews revealed a conflict in which R1 indicated staff agreed not to use specific chemicals anywhere in the facility and the staff indicate they agreed not to use specific chemicals in R1’s room only. Therefore the allegation is unsubstantiated, a finding of unsubstantiated means that although the allegation is vaild, the proponderance of the evidence standard has not been met.

An exit interview was conducted where a copy of this report was reviewed and provided to, Licensee Jaime Teng.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20220623154318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
10/07/2022
Section Cited
CCR
87555(b)(1)
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (1) Where all food is provided by the facility arrangements shall be made so that each resident has…daily food needs are met. Not more than fifteen (15) hours shall elapse between the third and first meal.” This requirement was not met as evidenced by:
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Licensee shall ensure that R1 receivs food everyday. Licensee will send LPA pictures of food trays being given to the resident. By POC due date.
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Based on interviews and records reviewed: facility staff did not provide food to a resident from 9pm on 6/9/2022 to 1pm on 06/10/22. This posed an immediate health and safety, or personal rights risk to R1.
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Type A
10/07/2022
Section Cited
CCR
87307(a)(3)
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87307 Personal Accommodations and Services (a) Living accommodations... The following provisions shall apply:(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. This requirment was not met as evidenced by:
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Licensee will ensure that commode is cleaned everyday, and resident is provided toilet paper and wipes. Licensee will send pictures of restocking residents room and clean commode.
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Based on interviews and record review, the facility staff did not provide a clean commode and toilet paper/wipes on 06/10/22 to R1. This posed an immediate personal rights or health or safety risk to R1.
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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
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20220623154318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
10/07/2022
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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Licensee will take a phot of the medications being given to resident and ensure that they are given every day.
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This requirment was not met as evidenced by:Based on interviews and record review, facility staff did not assist R1 with two medications on 06/10/22. This bin after assistance was requested on 06/10/22. This posed an immediate health and safety risk to R1.
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Type A
10/07/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Licensee will ensure resident is not called "evil" and take a screenshot of the resident saved in his phone by POC due date.
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Based on interviews and records review, the licensee saved R1’s name as “evil” in their phone, & sent R1 text messages about being evil. This posed an immediate personal rights risk to R1.
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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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20220623154318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
10/07/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature. This requirement was not met as evidenced by:
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Licensee will ensure interactions with resident are professional and cease to evict the resident. Licensee will send LPA photos of screenshots informing resident of this.
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Based on interviews and record review, facility staff refused to provide basic services to R1. Text messages also revealed R1 was sent texts threatening eviction and the facility would be closed.This posed an immediate personal rights, health or saftey risk to R1.
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Type B
10/17/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Licensee will ensure that residents room is clear of debris, and clean residents dirty dishes. Licensee will send phot of this being done by POC due date.
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Based on interviews and record review, facility staff did not clear out dirty dishes and full trash bin after assistance was requested on 06/10/22. This posed a potential health, safety or personal rights risk to R1.
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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
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20220623154318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/06/2022
NARRATIVE
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It was alleged that on June 10, 2022, staff did not provide R1 with toileting assistance. Interviews revealed R1 last had staff communicate with them at 9pm on June 9, 2022. R1 made attempts to communicate with staff in obtaining assistance with toileting but staff failed to respond. Attempts were made starting at 8am on June 10, 2022. R1’s responsible party arrived at approximately 1pm to assist R1 with toileting. Interviews were conducted with staff identified as being on duty on June 10, 2022. Staff interviews revealed S2 acknowledged they did not provide any assistance to R1 during their shift. S1 refused to answer interview questions. Therefore, based on interviews conducted and records reviewed, the allegation is substantiated.

It was alleged that R1 had a tray of dirty dishes and the trash was full. These items had been a concern since June 9, 2022 at approximately 9pm. Interviews revealed the staff had not answered phone calls for service nor their messages. R1 attempted to contact staff starting at 8am on June 10, 2022. Interviews were conducted with staff identified as being on duty on June 10, 2022. Staff interviews revealed S2 acknowledged they did not provide any assistance to R1 during their shift. S1 refused to answer interview questions. Therefore, based on interviews conducted, the allegation is substantiated.

It was alleged that on June 10, 2022 there were two medications not administered to R1. Interviews revealed that there are two medications stored in a refrigerator in the garage of the facility. LPA observed the two medications stored. Interviews revealed the staff had not answered phone calls for service nor their messages. R1 attempted to contact staff starting at 8am on June 10, 2022. Interviews were conducted with staff identified as being on duty on June 10, 2022. Staff interviews revealed S2 acknowledged they did not provide any assistance to R1 during their shift. S1 refused to answer interview questions. Therefore, based on interviews conducted, the allegation is substantiated.

It was alleged that staff are retaliating against R1. Interviews revealed R1 has made complaints and then staff threatened to evict the resident , close the facility and refuse to provide R1 services in retaliation for the complaints. Text messages were reviewed which revealed that licensee had stated the facility would close due to R1 complaining to licensing. Interviews revealed that staff refused to work with the resident and refused to provide services to the resident. Therefore, based on interviews conducted and records reviewed, the allegation is substantiated.
***CONTINUED ON LIC9099-C PAGE***
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
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20220623154318
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 10/06/2022
NARRATIVE
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It was alleged the licensee called R1 “evil.” Interviews revealed the name calling was done via text message. LPA conducted interviews and conducted records reviews. Text messages were reviewed which revealed a text message sent to R1 which read “I am so busy to create goodness not others who only spread evil.” The text message revealed it was sent from contact in phone "Jaime Teng". Interviews with the licensee revealed, the licensee admitted sending the text and he was speaking in generalities, and that the word “evil was not meant toward one person.” The licensee denied ever calling R1 evil. However, text message screenshots sent to the LPA by the licensee, revealed a text message exchange between the licensee and R1. The screenshot further revealed, R1’s contact information was saved using R1’s name followed by the word “evil”. Licensee stated that this word "evil" was a typo "evic" as in evicition. Therefore, based on interviews conducted and records reviewed, the allegation is substantiated.

During an interview conducted with the licensee it was revealed, the licensee was unable to be at the facility to assist R1 on June 10, 2022. The licensee stated that S1 and S2 were at the facility to provide care and supervision to the other residents that day. The licensee further revealed that S2 was assisting other residents during the time R1 was requesting assistance on June 10, 2022. The licensee also revealed that S1 did not want to assist the resident.

Based on interviews, review of records, and observations, a preponderance of evidence exists to support the allegations. The allegations are therefore substantiated. Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Licensee, Jaime Teng to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights were provided.
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
LIC9099 (FAS) - (06/04)
Page: 7 of 7