331880572-12-11-2024-18-AS-LMOA-DCH282-20241231160938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880572
Report Date: 12/10/2024
Date Signed: 12/11/2024 07:42:22 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2023 and conducted by Evaluator Lydia Martinez

COMPLAINT CONTROL NUMBER: 18-AS-20230130142356

FACILITY NAME:	PACIFIC VISTA SENIOR LIVING		FACILITY NUMBER:	331880572
ADMINISTRATOR:	TENG, JAMIE		FACILITY TYPE:	740
ADDRESS:	17085 BIRCH HILL ROAD		TELEPHONE:	(951) 850-1088
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92504
CAPACITY:	6	CENSUS: 6	DATE:	12/10/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Evangeline dela Rosa		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not assist resident when they reported breathing issues
Staff did not respond to resident when requesting food and water
Staff threatened and yelled at resident
Staff recorded resident in their bedroom without consent

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility by Evangeline dela Rosa and Edgardo Gonzales. LPA spole to Administrator Jamie Teng via telephone and reason for the visit was shared.
During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as obtained and reviewed pertinent documentation such as Resident Roster, Staff schedule, and Unusual Incident Report dated 01/26/2023. LPA observed facility to be clean and in good repair and observed residents to be well groomed and relaxing in their respective rooms on 11/21/2024 and 12/10/2024. Regarding allegation that staff did not assist resident when they reported breathing issues. LPA interviewed 2 of 2 staff (S1 and S2). S1 stated there is only one resident who uses a breathing machine (vaporizer). S1 stated resident will tell the staff of their need for the machine due to breathing issues and S1 or S2 will assist the resident. S2 also stated there is only one resident who uses a breathing machine, and will help resident when needed. S1 and S2 both denied that staff does not assist the resident when they are having breathing issues.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230130142356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PACIFIC VISTA SENIOR LIVING	FACILITY NUMBER: 331880572
	VISIT DATE: 12/10/2024

NARRATIVE

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Regarding allegation that Staff did not respond to resident when requesting food/water. LPA interviewed 2 of 2 staff, (S1 and S2). S1 stated residents are given three meals and two snacks every day. S1 stated the residents are encouraged to drink water throughout the day to stay hydrated. S2 stated he makes sure residents eat their breakfast, lunch and dinner and that the residents stay hydrated. Both S1 and S2 stated they would never deny a resident food or water if its requested. LPA interviewed R1 and R2. R1 stated food is good but could be better; would like to have more servings of fruits and vegetables. R1 is given food and water if requested. R2 denied allegation and added that the food is always excellent. During today's visit, LPA observed staff receiving a text message from Resident 6 (R6) requesting lunch. Staff prepared rice for the R6 per request.

Regarding allegation that staff threatened and yelled at resident. Interview with 2 of 2 staff (S1 and S2) and the Administrator (AD), AD denied yelling at any resident and stated he has never heard or received a complaint from a resident that staff yell at the residents. S1 denied yelling or hearing other staff yell at any resident. S1 did state there is a resident who yells at staff but staff would never yell at any resident. S2 stated he would not yell at a resident and denied hearing a staff member yell at the any resident. LPA interviewed R1 and R2. Both R1 and R2 denied being yelled or have not heard staff yell at residents.

Regarding allegation that staff recorded resident in their bedroom without consent. LPA interviewed 2 of 2 staff (S1 and S2) and the Administrator (AD). AD stated he has never recorded a resident with or without their consent. Both S1 and S2 stated they have not seen or heard of any staff member record any resident. Interview with R1 and R2, both stated they do not know if they or any resident has been recorded.

LPA interviewed two of six residents (R1 and R2) on allegations above. Three of six residents were unable to answer questions due to their diagnosis and the fourth resident avoided communication with LPA.

LPA was unable to verify above allegations occurred as reported. Although the above-mentioned allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur therefore the allegations are Unsubstantiated. An exit interview was conducted with AD and a copy of this report was sent to email on file.

SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC9099 (FAS) - (06/04)

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