336425397-8-15-2023-18-AS-RSTS-CYYSVX-20231229131325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425397
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:00:19 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
01/11/2021 and conducted by Evaluator Venus Mixson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210111160125

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: 0	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	02:28 PM
MET WITH:	ADMINISTRATOR, RANCE LETH.		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff speaks inappropriately to resident.
Staff tampered with resident's food.

INVESTIGATION FINDINGS:

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On August 15, 2023, Licensing Program Analyst (LPA), Venus Mixson made an scheduled visit due to the facility being closed and met with the Administrator, Rance Leth to deliver the findings on the above listed allegations. LPA Mixson introduced self and stated the purpose of the visit.

On 01/11/2021, Community Care Licensing (CCL) received information regarding the listed allegations. On 12/08/2021, LPA Mixson conducted staff and resident interviews and record reviews to obtain additional information. After LPA Mixson's evaluation of the evidence collected there was not a preponderance of the evidence strand to demonstrate if the alleged violations did occur.

Regarding the allegation staff speaks inappropriately to resident, the information obtained from interviews and record reviews revealed there was not sufficient evidence to demonstrate the listed allegation did or did not occur.

Regarding the allegation staff tampered with residents’ food, information obtained through interviews and records review did not meet the preponderance of evidence to demonstrate that the above listed allegation did in occur.

Based on the facility being closed and the LPA not able to contact additional staff and residents to obtain additional information pertaining to the listed allegations, the allegation findings have been deemed
"UNSUBSTANTIATED." An allegation finding of unsubstantiated means "although the allegation may have happened or is valid, there is not a preponderance of the evidence strand to prove the alleged violations 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 the Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus Mixson	TELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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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