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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881073
Report Date: 08/02/2022
Date Signed: 08/02/2022 01:16:52 PM


Document Has Been Signed on 08/02/2022 01:16 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: 165DATE:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Rance Leth - Executive DirectorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Executive Director Rance Leth and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Executive Director Rance Leth, and reviewed the facility's Mitigation Plan. Residents have hand sanitizer available to them (through staff in Memory Care and individually in Assisted Living), and the bathrooms were stocked with hand soap and paper towels. Upon entering the facility, LPA Colvin had her temperature taken in accordance with the updated visitation guidelines. LPA Colvin viewed the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin determined to be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Executive Director Rance Leth in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

Executive Director Rance Leth confirmed that all staff were fit tested for N95 masks. Executive Director Rance Leth confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility. LPAs Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. LPA Colvin confirmed with Executive Director Rance Leth that the facility is continuing to conduct surveillance testing for staff and follow isolation guidelines for both positive tests and staff experiencing COVID-19 symptoms.

An exit interview was conducted with Executive Director Rance Leth and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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