331881073-12-21-2021-18-AS-JESL-CETVUH-20220527164447

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881073
Report Date: 12/21/2021
Date Signed: 12/21/2021 04:26:15 PM

Unfounded

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
12/17/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211217115444

FACILITY NAME:	PACIFICA SENIOR LIVING MENIFEE		FACILITY NUMBER:	331881073
ADMINISTRATOR:	LETH, RANCE		FACILITY TYPE:	740
ADDRESS:	28333 VALLEY BOULEVARD		TELEPHONE:	(951) 679-8811
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	220	CENSUS: 167	DATE:	12/21/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Executive Director Rance Leth		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Resident sustained a fall while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to deliver findings for the allegation listed above. LPA met with Executive Director Rance Leth and explained the purpose of the visit and element of the allegation. The department investigated the allegation of resident sustained a fall while in care. The investigation consisted of observation, interviews and a review of pertinent documentation.

LPA reviewed internal communication logs as well as incident reports, the documents noted revealed that Resident #1(R1) resides in memory care, and staff described R1 as being a high functioning, and very active. Began to experience dizziness, confusion and paranoia. These behaviors are described as not the unusual behavior for R1. As a result R1 was sent out for a medical evaluation three different times:12/9/21, 12/12/21, and 12/14/21. R1 was diagnosed with Pneumonia and was discharged after being treated at a local hospital. Each time upon R1s return to the facility staff noted for R1 to be off balance, confused, dizzy and paranoid (hiding from the light). Recently, on December 14, 2021 R1 returned to the facility exhibiting the same behaviors of confusion and hallucination.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211217115444

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: 12/21/2021

NARRATIVE

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Within 15 minutes of R1s return to the facility, R1 sustained a fall. At the time of the fall there were a total of four (4) staff in the memory care, with a census of 21 residents in the unit.

To date R1 has not returned to the facility due to being transferred to a skilled nursing facility.
The documentation reviewed indicate that R1 may have been discharged too soon, due to the on-going behaviors that they were exhibiting, based on interview and record review the allegation of Resident sustained a fall while in care is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided to Executive Director Lance Reth.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021

LIC9099 (FAS) - (06/04)

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