336425840-8-4-2021-18-AS-CCON-C5KRFT-20210804125940

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425840
Report Date: 08/04/2021
Date Signed: 08/04/2021 12:59:47 PM

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
RIVERSIDE, CA 92507

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: 80	DATE:	08/04/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Eva Tawfik - Executive Director/Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Executive Director/Program Administrator Eva Tawfik and the Memory Care Director, and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with the Administrator and Memory Care Director, who LPA Colvin found to be successfully incorporating the several aspects of the facility's approved Mitigation Plan. Since the entire facility is locked Memory Care, the residents do not have direct access to soap and hand sanitizer, but instead facility care staff provide these items to them and supervise them while they wash their hands or apply the hand sanitizer. LPA Colvin observed hand washing reminders and directions to be posted over sinks that staff use, such as kitchen sink. LPA Colvin additionally observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information. LPA Colvin requested to inspect the facility's Personal Protective Equipment (PPE) supply, which is stored in a few different areas of the facility which are accessible to staff. LPA Colvin observed the facility to have a 30-day supply of gloves, surgical masks, and sanitizer, and isolation gowns. LPA Colvin observed the facility to only have a small supply (approximately 8 small boxes) of N95 masks. The Memory Care Director informed LPA Colvin that the corporate office is now allowing the facilities to request PPE items from them, whereas previously the facility had to order from an outside source. LPA Colvin will be issuing a Technical Assistance Advisory Note instead of a deficiency due to the facility not currently have any COVID-19 positive cases, which staff only need to wear an N95 for in such a circumstance.. LPA Colvin advised the facility to purchase or request from their corporate office for additional N95 masks to insure that they have a 30-day supply at all times.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 08/04/2021

NARRATIVE

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LLPA Colvin went over the various recommended training for facility staff in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin inquired as to if staff have been fit tested for N95 masks, and the Administrator and Memory Care Director informed LPA Colvin that at this time staff have not been fit tested. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. LPA Colvin will be providing Licensee/Administrator with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

LPA Colvin inquired about if the facility is still conducting COVID-19 surveillance testing of their staff members. Administrator Eva Tawfik and the Memory Care Director informed LPA Colvin that staff are continuing to test for COVID-19 on a weekly basis, in accordance with Community Care Licensing recommendations. LPA Colvin additionally informed Administrator Eva Tawfik of the new PIN (PIN 21-32-ASC) which came last week and advised that as of 8/9/21, the new guidance for facilities will be to resume COVID-19 testing for staff, due to the increase of COVID-19 cases. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Eva confirmed that staff are continuing to monitor residents symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility. LPA Colvin observed sign-in logs at the facility's entrance which documents visitor's temperature. No deficiencies cited.

An exit interview was conducted with Administrator Eva Tawfik and a copy of this report and LIC9102 TA Advisory Notes were provided.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC809 (FAS) - (06/04)

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