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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881073
Report Date: 06/05/2024
Date Signed: 06/05/2024 02:06:30 PM


Document Has Been Signed on 06/05/2024 02:06 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: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: 200DATE:
06/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:04 PM
MET WITH:ADMINISTRATOR, RANCE LETHTIME COMPLETED:
02:09 PM
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On June 05, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Rance Leth. The facility file review was conducted in the Regional Office and additional forms were reviewed and requested on site. The facility is licensed for 220 ambulatory residents and has a waiver for 10 non-ambulatory residents. The facility currently operating at 200 residents of which 13 residents are on hospice, and about 30 residents in memory care.

LPA Mixson toured the facility and inspected the facility inside and outside, and there were no obstructions to the indoor or outdoor passageways at the time of this visit. The facility is a three floored facility located at 28333 Valley Blvd, Sun City, CA. 92586.

Physical Plant: The facility phone number is(951) 679-8811. The LPA observed a sampling of the residents’ living units, and they were equipped with required furniture as per Title 22. LPA Mixson inspected a sampling of the facility restrooms, and the hot water temperature tested within regulations. The restrooms were clean, and appliances were operating appropriately currently at the time of this visit. The facility is equipped with operating smoke detectors, carbon monoxide alarms, and fire extinguishers. The LPA observed required postings such as "If you See Something, Say Something" the "Personal Rights" and the Ombudsman postings. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care currently at the time of this visit. There was a pool and jacuzzi present which was fenced in meeting the height requirements.

Medications: were locked and inaccessible to residents in care and located in the "Wellness Center." The overall facility is clean, the furniture is in good condition. The facility cooling system and other appliances were operable currently at the time of this visit, and there were safety lights throughout the building.

Food Service: Non-perishable and perishable food supply is sufficient per regulations, and there are a variety of food types available for residents. Kitchen utensils were in sufficient supply and stored properly, and sharps are locked.

Care & Supervision: Facility has sufficient staff on site at the time of this visit.

Records Review: The LPA reviewed resident and staff files, conducted staff and resident interviews. Previous Community Care Licensing forms were reviewed. There were no Title 22, Division 6 Regulation violations observed or cited during today’s visit.

An exit interview was conducted, and a copy of this report was given to the Administrator, Rance Leth.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024
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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