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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880572
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:20:47 PM


Document Has Been Signed on 08/15/2023 03:20 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:
08/15/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Licensee, Jaime TengTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Janira Arreola and Licensing Program Manager (LPM) Joel Esquivel conducted an informal office meeting with the administrator and licensee Jaime Teng, Corporate Board Member of RIVERSIDE ELITE ADVANTAGE CARE HOME LLC. The following items were discussed:
  • The administrator failed to provide plan of correction for deficiency cited on 8/4/2023 for Eviction Procedures. The licensee was provided with a copy of eviction procedures in California Code of Regulations under Title 22. During this meeting, the licensee stated they would be informed on eviction procedures to ensure that residents receive a proper eviction when it is required.
  • Licensee unprofessional behavior during 8/4/2023 visit. The licensee agreed during today's meeting to act in a professional manner with CCL staff.
  • In regards to staff competency the licensee agreed to provide training to improve staff competency. They agreed they would be at the facility 20 hours a week at the facility Monday to Sunday from 8am to 12pm and agreed to amend the staff roster to reflect this.
  • In regards to prior complaint allegations, Licensee agreed to provide more training to staff and be more receptive to facility residents to prevent future complaints.
  • In regards to facility Intake process the licensee agreed to have all required paperwork at the facility prior to accepting a new resident.
  • Reporting requirements. The licensee was provided with the public inbox for reporting incidents at the facility in a timely manner: CCLASCPRO@dss.ca.gov
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
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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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
VISIT DATE: 08/15/2023
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  • In regards to facility records, the licensee agreed to have the records available at the facility and ready for LPA's inspection.
  • In regards to unassociated staff, the licensee agreed to check the facility roster and make sure all staff are associated prior to working at the facility.

An exit interview was conduced where this report was reviewed and provided to the Licensee, Jaime Teng.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
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