336425397-1-19-2023-18-AS-RLAY-CNLLST-20230131080113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425397
Report Date: 01/19/2023
Date Signed: 01/19/2023 02:38:54 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
01/12/2021 and conducted by Evaluator Yolanda Delgado

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210112113406

FACILITY NAME:	PACIFICA SENIOR LIVING MENIFEE		FACILITY NUMBER:	336425397
ADMINISTRATOR:	LETH, RANCE		FACILITY TYPE:	740
ADDRESS:	28333 VALLEY BLVD		TELEPHONE:	(951) 679-8811
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	0	CENSUS: 169	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Rance Leth, Executive Director		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff left resident in soiled clothing for extended period of time

INVESTIGATION FINDINGS:

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On January 12, 2021, Community Care Licensing received information which stated staff left resident in soiled clothing for extended period of time. The investigation included interviews and review of documents. It was reported that R1 was left in soiled clothing. It was reported that when R1 was picked up to be transported to a doctor's appointment, R1's pants were soiled. It was reported that R1 was changed immediately. No other incidents of R1 being left in soiled clothing were advised. Information obtained from additional witnesses stated that R1's condition changed and it was advised that R1 would need to be placed in diapers to assist with changing requirements. Facility staff stated that R1 was not left in soiled clothing and that R1 was changed every 1-2 hours due to R1's condition. Documentation was provided to support the change in the level of care.

Based on interviews and the review of pertinent documentation, the above allegation may have occurred, however is not supported or proved by evidence. Therefore, the allegation is unsubstantiated at this time. The preponderance of evidence standard has not been met.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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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