336425840-6-26-2024-56-AS-EMAN-D9HQJJ-20240927121245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336425840
Report Date: 06/26/2024
Date Signed: 06/26/2024 05:36:59 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
01/26/2024 and conducted by Evaluator Mary Rico

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240126151948

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: 65	DATE:	06/26/2024
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Julie Schevette		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

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Staff do not ensure that residents' toothbrushes are stored in a sanitary manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Sales Director Julie Schevette and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, document reviews, and facility tour.

For the allegation, Staff do not ensure that residents' toothbrushes are stored in a sanitary manner.

LPA Rico conducted 7 staff interviews. 7 out of the 7 staff informed LPA that residents toothbrushes were not stored in a sanitary manner. 7 out of the 7 staff indictaed all resident’s toothbrushes were stored in a mix bin without a lid and had no name label.1 out of 7 staff stated they indeed provided R1 with a toothbrush that was not stored in sanitary manner to their appointment on 1/24/2024.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

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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Control Number 56-AS-20240126151948

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/26/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/28/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	Administrator will send LPA they have understood and read the regulation.
	8 9 10 11 12 13 14		8 9 10 11 12 13 14	POC due date 6/28/2024
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240126151948

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 06/26/2024

NARRATIVE

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Based on the evidence gathered during today’s investigation, the one (1) allegation listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

During today’s visit, one (1) deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Sales Director Julie Schevette, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024

LIC9099 (FAS) - (06/04)

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