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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604134
Report Date: 01/31/2024
Date Signed: 01/31/2024 12:03:09 PM


Document Has Been Signed on 01/31/2024 12:03 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
CCLD Regional Office,
, CA



FACILITY NAME:PACIFICA SENIOR LIVING VISTAFACILITY NUMBER:
374604134
ADMINISTRATOR:ENCISO, KARENFACILITY TYPE:
740
ADDRESS:760 EAST BOBIER DRIVETELEPHONE:
(760) 941-1480
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:252CENSUS: 107DATE:
01/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Michael McCoy, Executive DirectorTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced visit to deliver findings for a complaint investigation and in conjunction conduct this case management visit regarding the residents rights. LPA identified herself and was granted entry by Jonalyn Libunao, Business Office Manager. LPA stated the purpose of the visit and reviewed the elements of the case management visit with Executive Director Michael McCoy, and Esmeralda Reyes, Resident Service Director (RSD).

The Department’s investigation regarding the complaint dated December 7, 2020, control number 08-AS-20201125155602, resulted in unsubstantiated findings, but a discrepancy was observed during the review of resident records. Based on the Needs and Service Plan for resident #1 (R1 – see LIC811 Confidential Names list), dated 08/17/2020, the plan was incomplete and did not have R1 or their responsible party’s signature. It should also be noted that the Authorized Community Representative signature was not on the updated plan as well.

During today’s visit, LPA reviewed Title 22, Division 6, Chapter 8, Sections 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities, specifically section (a)(7). Based on the Department’s investigation and the evidence obtained during records review, deficiencies are cited during this case management visit and can be viewed on the LIC809-D page of this report.

The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Executive Director McCoy, and Resident Service Director Reyes. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to ED McCoy at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/31/2024 12:03 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
CCLD Regional Office,
, CA


FACILITY NAME: PACIFICA SENIOR LIVING VISTA
FACILITY NUMBER: 374604134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2024
Section Cited
CCR
87468.2

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(7) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding care and services to be provided, according to Health and Safety Code section 1569.80 and involve persons of their choice in this planning. The licensee shall provide necessary information and support to ensure that residents direct the planning of their care to the maximum extent possible, and are enabled to make informed decisions and choices… this requirement was not met as evidenced by:
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Facility will be conducting staff training for resident service plans and submit the training documents for staff ED, RSD, MCD, and RCC to be provided training. Documents will be submitted to LPA by POC due date, 02/16/2024.
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Based on LPA’s records review, the Facility did not ensure that the resident or their representative were updated in the resident’s care plan which poses a potential personal rights risk to 1 [R1] of 127 residents in care.
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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: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
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