336425840-1-12-2023-56-AS-KCLS-CQCVF8-20230328162333

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 09/20/2022
Date Signed: 01/12/2023 09:25:58 AM

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/16/2022 and conducted by Evaluator Javier Prieto

COMPLAINT CONTROL NUMBER: 56-AS-20220916095709

FACILITY NAME:	PACIFICA SENIOR LIVING RIVERSIDE		FACILITY NUMBER:	336425840
ADMINISTRATOR:	EVA TAWFIK		FACILITY TYPE:	740
ADDRESS:	6280 CLAY STREET		TELEPHONE:	(951) 360-1616
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	110	CENSUS: 90	DATE:	09/20/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Eva Tawik		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation for the above allegation. LPA Prieto toured facility with S1 to the area in reference at the facility. LPA Prieto observed a sprinkler that was being repaired which did not effect any other functions related to the operation of the facility. LPA did not observe any damage to the facility cider block wall or damage to any other fence adjacent to the facility wall. S2 provided LPA Prieto with City inspection notice, which facility staff are addressing.

Based on the information obtained there is not enough evidence that facility is in disrepair. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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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