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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425840
Report Date: 03/29/2023
Date Signed: 03/29/2023 03:21:51 PM


Document Has Been Signed on 03/29/2023 03:21 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
, CA 92507



FACILITY NAME:PACIFICA SENIOR LIVING RIVERSIDEFACILITY NUMBER:
336425840
ADMINISTRATOR:EVA TAWFIKFACILITY TYPE:
740
ADDRESS:6280 CLAY STREETTELEPHONE:
(951) 360-1616
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:110CENSUS: 78DATE:
03/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Eva Tawfik, Executive Director TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit regarding an incident where a resident (R1) AWOLed from the facility on 03/02/2023. Facility video surveillance footage observed R1 scaling the facility fence and into a transport vehicle and exited the facility parking lot. Footage shows staff immediately calling out for help and attempting to open the double egress locks of the gate in order to stop the vehicle from leaving. Several staff took vehicles to attempt to locate R1 and notified local law enforcement. Facility staff attempted to phone R1 and when they got in contact with R1 no specific information was given as to the whereabouts. Law enforcement located R1 two days after later and returned to the facility. R1's responsible party was notified of the AWOL and subsequent return the facility. Responsible party then submitted paperwork relinquishing power over R1. R1 was interviewed by LPA Prieto in his room at the facility and found to be in good health, but does not understand why he is at the facility instead of his own private home. Staff interviews tells us that R1 did not have a residence prior to being admitted to the facility who was place at the facility by a family member who is also R1's power of attorney. LPA gathered pertinent documentation and this report was signed by Director Tawfik.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
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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