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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881073
Report Date: 11/08/2023
Date Signed: 11/08/2023 04:38:43 PM


Document Has Been Signed on 11/08/2023 04:38 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
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: 172DATE:
11/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Administrator, Rance LethTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 2:21pm to make an unannounced Case Management visit to the facility. LPA met Administrator, Rance Leth and explained the purpose of the visit.

On 11/08/23 at 3:32PM, LPA observed live roaches and roach casings and eggs in 1/3 resident bedrooms and active bug bites on the residents in 3/3 resident bedrooms. LPA observed roaches running across the door, kitchen, floor, and bathroom floors. The residents in all 3 bedroom had either bite marks or rashes on their arms from the infestation. The Administrator stated he was aware of the infestation of roaches in the resident's room and treatment started 1 week ago for the resident and their neighbor but was unaware of issue in any other resident's room. The facility was cited for CCR 87303 (a) The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

The facility is not in compliance with Title 22 Regulation, the deficiency can be found on the LIC 809-D page.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl GoodrichTELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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 11/08/2023 04:38 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: PACIFICA SENIOR LIVING MENIFEE
FACILITY NUMBER: 331881073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2023
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The Administrator indicated that Black Knight will be coming out for another visit either tomorrow or the following day. The Maintenance Director states they will approach the issue with a smile and try not to make it seem like they are mad when responding to the resident's complaints
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Based on observation and interview, the Administrator did not ensure that the facility is clean, safe, sanitary, and in good repair at all times. The facility did not ensure that maintenance include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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 The Maintenance Director states they will approach the issue with a smile and try not to make it seem like they are mad when responding to the resident's complaints

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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: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl GoodrichTELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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