<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881073
Report Date: 04/05/2023
Date Signed: 04/05/2023 01:54:45 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
11/21/2022 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221121162823
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: 180DATE:
04/05/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rance Leth, Executive DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to check on the safety of resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA met with Executive Director (ED), Rance Leth, and informed him of the purpose of the visit.

A report was received alleging Resident One (R1) fell in their bedroom on or around November 13, 2022, and was not found by facility staff until November 15, 2022. The LPA conducted staff/resident interviews, reviewed records, and took copies of relevant documentation. An Unusual Incident Report (UIR) was obtained and revealed R1 was found on the floor of their bedroom on November 15, 2022. Staff interviews revealed there are residents, R1 included, who request less frequent checkups by staff. One interview revealed staff checked on R1 once or twice on November 13, 2022, and once on November 15, 2022. A second interview revealed staff did not check on R1 on November 14, 2022. A third-party interview revealed R1 missed a scheduled appointment on November 14, 2022, at the facility. In addition, a staff interview revealed R1 appeared dehydrated when found on November 15, 2022. Therefore, based on interviews, this allegation is deemed
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
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 3
Control Number 18-AS-20221121162823
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: PACIFICA SENIOR LIVING MENIFEE
FACILITY NUMBER: 331881073
VISIT DATE: 04/05/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 SUBSTANTIATED. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted; this report was reviewed with ED Leth and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20221121162823
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: PACIFICA SENIOR LIVING MENIFEE
FACILITY NUMBER: 331881073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2023
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
BASIC SERVICES: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met, as evidenced by: Based on interviews the Licensee did not ensure R1 received supervision. Interviews
1
2
3
4
5
6
7
ED Leth stated a statement would be submitted indicated more frequent check ups will be conducted for residents in care.
8
9
10
11
12
13
14
revealed staff checked on R1 once or twice on 11/13/2022 & once on 11/15/2022; staff did not check on R1 on 11/14/2022; R1 missed a scheduled appointment on 11/14/2023 at the facility; & R1 appeared dehydrated when found on 11/15/2022.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3