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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800055
Report Date: 08/23/2021
Date Signed: 03/07/2024 10:59:57 AM

Document Has Been Signed on 03/07/2024 10:59 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:PACIFICA SENIOR LIVING HEMETFACILITY NUMBER:
331800055
ADMINISTRATOR:CRISTINA MILLERFACILITY TYPE:
740
ADDRESS:1177 S PALM AVETELEPHONE:
(951) 923-2844
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 110CENSUS: 69DATE:
08/23/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Barbara Bogoje, Resident Services DirectorTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst Yolanda Delgado is conducting a Case Management while conducting a visit for complaint #18-AS-20210816150952. LPA asked if there are any positive cases for COVD-19 in the facility, receptionist advised that she will need LPA to speak to the Nurse first. Nurse arrived and advised there is a resident that is COVID-19 Positive, during the screening questions for the resident, it was also reported a staff tested COVID-19 positive the week prior of the resident that tested COVID-19 positive. A citation was issued failure for reporting requirements to CCLD.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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Document Has Been Signed on 03/07/2024 10:59 AM - It Cannot Be Edited


Created By: Yolanda Delgado On 08/23/2021 at 04:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HEMET
FACILITY NUMBER: 331800055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2021
Section Cited
CCR
87211(a)(1)

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REPORTING REQUIREMENTS:
(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Management states upon receiving positive report, Management will notify CCLD via Fax, follow-up with a phone call and then call the County of Public Health to obtain the directions. Management will do in-service
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This requirement was not met as evidence by:
The facility did not provide CCLD with writen notification of one positive COVID-19 staff. Potential health, safety risk, and personal rights to residents in care.
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training with Staff regarding COVID-19 positives. In stand-up meetings held daily Monday through Fridays to update the team with new COVID cases. Statement of understanding and training due by 9/6/2021.

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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:Efren Malagon
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021


LIC809 (FAS) - (06/04)
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