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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425840
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:49:04 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 RIVERSIDEFACILITY NUMBER:
336425840
ADMINISTRATOR:EVA TAWFIKFACILITY TYPE:
740
ADDRESS:6280 CLAY STREETTELEPHONE:
(951) 360-1616
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:110CENSUS: 84DATE:
11/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Usman ChaudaryTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Jennifer Semin conducted an unannounced case management visit to discuss an incident report received at the Community Care Licensing Regional Office on 10/29/2021 for an incident which occurred on 10/9/2021. It was reported that a staff member hit a resident. LPA met with Resident Care Director, Usman Chaudary and Business Office Manage, Richard Lopez.

LPA discussed the incident report with Mr. Chaudary and Mr. Lopez. LPA reviewed staff files and other pertinent documents. According to staff records, staff have received mandated reporter training prior to the incident.
Mr. Chaudary stated internal interviews revealed, Staff 1 (S1) did not report the incident immediately because S1 feared retaliation from Staff 2 (S2). S2 denied hitting the resident.
Mr. Chaudary was advised that additional information including, interviews, calls, and record review may be needed to complete the case management inquiry.

An exit interview was conducted where this report was discussed and provided to Mr. Chaudary.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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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