336425840-10-4-2023-56-AS-MMAE-CWAVE7-20231004162150

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425840
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:26:46 PM

Document Has Been Signed on 10/04/2023 04:26 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
SAN BERNARDINO, 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: 89	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Eva Tawfik, Executive Director		TIME COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Eva Tawfik, Executive Director, and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). Licensed capacity is (110) with a current census of (89). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected all six (6) resident cottages inside and out. Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient indoor and outdoor activity space for residents in care. Activities are posted in a common area of each cottage. All cottages are enclosed with self-latching gates. Facility has no bodies of water.

LPA inspected the kitchen. Facility has sufficient non-perishable and perishable food for the number of residents in care. Menus are posted in various areas of the facility. Facility food is stored in a safe and healthful manner. Sharps are stored and kept locked and inaccessible to residents.

LPA inspected resident bedrooms. Bedrooms are equipped with beds, bed linen, chairs, nightstands, storage space and sufficient lighting.

LPA inspected resident bathrooms. Bathrooms were equipped with grab rails and operating bathroom equipment. The hot water in four (4) bathrooms tested below

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2023

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regulation requirement. Bathrooms in rooms 202, 203, 404, 506 tested between 86 to 96 degrees F.

LPA observed the facility is equipped with operating carbon monoxide alarms and telephone service. Facility has a complete first aid kit. Posters such as personal rights, Ombudsman Poster, the disaster plan and emergency numbers were posted in a common area.

LPA reviewed six (6) client medications and centrally stored medication logs. All medications are labeled and administered as prescribed.

LPA reviewed six (6) staff files for criminal record clearances, trainings, and health screenings. Employed staff 1 (S1) did not have a criminal record clearance.

LPA reviewed six (6) resident records for admissions agreements, physician's report, pre-admission appraisals and emergency contacts. All records had the required documentation.

Deficiencies were cited during today's visit and a plan of correction was discussed with Executive Director Tawfik. Copies of reports (LIC809/809-D/LIC9102) with appeal rights were provided to the Executive Director at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2023 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by having Staff 1 (S1) employed at the facility without a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	Licensee/Director shall submit to the licensing agency by POC datea statement of understanding that no staff shall be permitted to work at the facility until receipt of a criminal record clearance or exemption.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2023 04:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

87303 (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by the hot water tempertature in four (4) resident bathrooms testing below regulation requirement. Bathrooms in rooms 202, 203, 404, 506 tested between 86 to 96 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee/Director shall submit to the licensing agency by POC date proof that hot water temperatures are in regulation through maintenance receipts.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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