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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880572
Report Date: 10/05/2023
Date Signed: 10/05/2023 10:54:52 AM


Document Has Been Signed on 10/05/2023 10:54 AM - 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:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Jamie Teng, AdministratorTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit as LPA was delivering findings for complaint control # 18-AS-20230803114230 and observed the following deficiency.

The facility admitted (accepted responsibility) for Resident #1 (R1) on or around August 3, 2023. Per interviews with Administrator Jamie Teng, there is a contract or agreement with a local skilled nursing facility (SNF) to discharge residents from the SNF to the facility. However, the facility is accepting residents without properly screening them, as well as not completing the evaluation of suitability for admission. The evaluation consists of: (1) Conduct an interview with the applicant and his responsible person. (2) Perform a pre-admission appraisal. (3) Obtain and evaluate a recent medical assessment).

As a result of the facility not properly screening new residents. R1 was admitted to the facility and began exhibiting aggressive behaviors such as banging their head against the wall, and trying to throw furniture. As a result the facility had to contact 9-11 to assist, and have R1 removed without returning to the facility. This poses a potential health, safety and personal rights risk to persons in care.

The following is being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report, and appeal rights were reviewed and provided to Administrator Jamie Teng.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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Document Has Been Signed on 10/05/2023 10:54 AM - 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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
87456(a)(1-3)

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87456 Evaluation of Suitability for Admission (a)(1-3) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (1) Conduct an interview with the applicant and his responsible person. (2) Perform a pre-
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The licensee agrees to submit a personal statement self certifying that any new residents moving forward the facility will conduct an evaulation of suitability.
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admission appraisal. (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: The licensee failed to conduct an evaluation for R1, 1 time. This posed a potential health, safety and personal rights risk to persons 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) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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