331881073-4-5-2023-18-AS-JDHS-CRBSZS-20230428141937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881073
Report Date: 04/05/2023
Date Signed: 04/05/2023 01:58:55 PM

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
03/30/2023 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230330111640

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: 180	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:	Rance Leth, Executive Director		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff continued to administer medication after it was discontinued by doctor

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Executive Director (ED), Rance Leth, and informed him of the purpose of the visit.

A report was received alleging facility staff administered one discontinued medication to Resident One (R1) from February 21, 2023 through March 21, 2023. The LPA conducted staff/resident interviews, reviewed records and took copies of relevant documentation. Medication Aministration Records (MAR) from February and March 2023 were reviewed. The reports revealed the facility did administer to R1, from February 21, 2023 to March 23, 2023, the medication allegedly discontinued. Physican Orders were reviewed and it was found the medication administered to R1 was discontinued on February 21, 2023; however, the document was not signed and dated. Therefore, due to insufficient information, this allegation is deemed UNSUBSTANTIATED at this time. This report was reviewed with Leth and a copy was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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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