331881073-5-17-2022-18-AS-JESL-CETVVM-20220527164635

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881073
Report Date: 05/17/2022
Date Signed: 05/17/2022 09:31:58 AM

Unsubstantiated

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
03/21/2022 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220321152507

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: 179	DATE:	05/17/2022
		UNANNOUNCED	TIME BEGAN:	08:33 AM
MET WITH:	Rachelle Wheaton,Resident Care Director		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Facility did not safeguard resident's personal items.

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 Rachelle Wheaton, Resident Care Director and explained the purpose of the visit and elements of the allegation. The department investigated the allegation of Facility did not safeguard resident's personal items. The investigation consisted of observation, interviews and a review of documentation.

The missing items are a pendant, 4 rings, and a bracelet that was given to Resident #1 (R1) by their spouse. R1 is in a private room that includes an in room safe to lock to store items of value. Per Executive Director Rance, Residents are the only ones with access to the in room safe, if a resident was to lose a key or move out, the lock smith would have to come out to remove and replace with a new lock. Additional interviews conducted revealed that there was not any supporting documentation such as a receipt, or even photographs of the items in question.

Unsubstantiated

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: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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-20220321152507

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: 05/17/2022

NARRATIVE

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Additionally, LPA reviewed documentation such as R1s resident personal property and valuables form. The form has the typed statement "I do not wish to list any items at this time" that is signed by R1, at the time of admission to the facility. It is unknown as to when the items in question entered the facility or if they did.

Due to lack of evidence to support that R1 had the missing items and brought them to the facility the allegation of Facility did not safeguard resident's personal items is UNSUBSTANTIATED.

A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted and a copy of this report was provided to Rachelle Wheaton, Resident Care Director.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC9099 (FAS) - (06/04)

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