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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881073
Report Date: 12/30/2022
Date Signed: 12/30/2022 12:54:58 PM


Document Has Been Signed on 12/30/2022 12:54 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: 172DATE:
12/30/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Rance Leth, Executive Director
Rachelle Wheaton, Resident Care Director		TIME COMPLETED:
01:05 PM
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On December 30, 2022, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit to check on the health, safety, and welfare of residents in care. LPA met with Executive Director, Rance Leth and Resident Care Director, Rachelle Wheaton and explained the purpose of the visit.

During today’s visit, LPA Nwogene toured the facility with Rance and no health and/or safety concerns were observed. LPA Nwogene observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well.

During this visit, LPA also interviewed Executive Director and Resident Care Director, reviewed residents file, and obtained copies of pertinent documents.

Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted were this report and LIC811 was discussed with and provided to Rance Leth.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022
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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