336425840-11-5-2024-56-AS-BMAN-DAQSKT-20241105125717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425840
Report Date: 11/05/2024
Date Signed: 11/05/2024 12:57:31 PM

Document Has Been Signed on 11/05/2024 12:57 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PACIFICA SENIOR LIVING RIVERSIDE		FACILITY NUMBER:	336425840
ADMINISTRATOR/ DIRECTOR:	EVA TAWFIK		FACILITY TYPE:	740
ADDRESS:	6280 CLAY STREET		TELEPHONE:	(951) 360-1616
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY: 110	TOTAL ENROLLED CHILDREN: 0	CENSUS: 76	DATE:	11/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Eva Tawfik, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	01:05 PM

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Licensing Program Analysts (LPAs) Becky Mann and Javier Prieto made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Eva Tawfik, Executive Director and Annette Buenrostro, Memory Care 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 76. LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPAs 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.

LPAs 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.

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

LPAs inspected resident bathrooms. Bathrooms were equipped with grab rails and operating bathroom equipment. The hot water in the bathrooms tested between 109-110 degrees Fahrenheit.

LPAs 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.

Nedra Brown	TELEPHONE: (951) 202-5776
Becky Mann	TELEPHONE: 951-248-0306
	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 11/05/2024

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LPAs reviewed ten (10) resident medications and centrally stored medication logs. All medications are labeled and administered as prescribed.

LPAs reviewed five (5) staff files for criminal record clearances, trainings, and health screenings. All staff records were up-to-date.

LPAs reviewed ten (10) resident records for admissions agreements, physician's report, pre-admission appraisals and emergency contacts. All records had the required documentation.

No deficiencies were cited during today's visit and copy of the reports LIC809 and LIC809-C were provided to the Executive Director at the conclusion of the visit.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Becky Mann	TELEPHONE: 951-248-0306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

LIC809 (FAS) - (06/04)

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