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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881073
Report Date: 06/21/2023
Date Signed: 06/29/2023 09:53:10 AM


Document Has Been Signed on 06/29/2023 09:53 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:PACIFICA SENIOR LIVING MENIFEEFACILITY NUMBER:
331881073
ADMINISTRATOR:LETH, RANCEFACILITY TYPE:
740
ADDRESS:28333 VALLEY BOULEVARDTELEPHONE:
(951) 679-8811
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:220CENSUS: 173DATE:
06/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Rance LethTIME COMPLETED:
08:35 PM
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Licensing Program Analyst (LPA) Cheryl Goodrich conducted an unannounced annual visit. LPA met the Administrator Rance Leth at the front desk and was granted entry. Advised Lance of the purpose of today’s visit, to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The facility is approved for two hundred and twenty (220) ambulatory residents and has a waiver for 10 non-ambulatory residents. The facility currently has 173 residents of which 13 residents are on hospice, and 7 are in memory care.

Physical Plant: front entrance, interior and surrounding exterior were clean and in good repair with no pathway obstruction; doorway alarms were in working order; residents' apartments consisted of bedroom with clean mattress and linen; and shower present with grab bars for assistance; there was sufficient lighting and mattress pads in all of the residents' bedrooms; fire alarm and smoke carbon monoxide detectors were in working order. There was a pool and jacuzzi present which was fenced in meeting the height requirements.


Food Services: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available to residents.
Medication/Facility Records: Medications were observed to be labeled and in a locked place that is inaccessible to residents. All staff subject to a criminal record review obtained fingerprint clearance and/or an exemption. Staff responsible for direct care and supervision have current First Aid / CPR training. Licensee has completed a written admission agreement, current medical assessment and needs and service plan with each resident. Exceptions & waivers are in place and meet said terms. Licensee handles no resident cash resources. Administrator Certificate is current and will expire on 05/22/24.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Administrator Rance Leth and a copy of this report was printed Signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl GoodrichTELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
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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