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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880572
Report Date: 12/13/2024
Date Signed: 12/13/2024 01:52:16 PM

Document Has Been Signed on 12/13/2024 01:52 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:PACIFIC VISTA SENIOR LIVINGFACILITY NUMBER:
331880572
ADMINISTRATOR/
DIRECTOR:		TENG, JAMIEFACILITY TYPE:
740
ADDRESS:17085 BIRCH HILL ROADTELEPHONE:
(951) 398-7331
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 6CENSUS: 6DATE:
12/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Evangeline dela RosaTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez, made this Case Management visit in conjunction with complaint investigation visit for numbers 18-AS-20230130142356 and 18-AS-20230616162648. LPA met with Evangeline dela Rosa and reason for visit was shared. Administrator Jamie Teng was informed of LPA LPA's presence at the facility.
There were six residents present during visits conducted on 11/21/2024, 12/10/2024 and 12/13/2024. Residents were observed clean and warm. Facility was maintained at a comfortable temperature for the residents in care. The needs of the residents in care appeared to be met. During the investigation, LPA toured the facility and observed the following:
On 11/21/2024 LPA observed six (6) bottles of vitamins/medication (picture) in a Ziploc bag in the kitchen refrigerator. Staff removed the bag and locked it away. On 12/10/2024, LPA observed the same Ziploc bag of vitamins in the kitchen refrigerator and staff removed the bag. Same Ziploc bag with vitamins was again observed in the kitchen refrigerator on today's date. Staff removed the bag of vitamins. On 11/21/2023 and 12/10/2023, LPA observed the facility’s perishable food supply to be less than the requirement for the residents in care. On today's date, LPA observed plenty of fruits and vegetables for the residents. LPA observed Resident 1 (R1) with 3 half bed rails tied with a shoelace around R1’s bed (2 half bed rails to make a full rail and 1 half bed rail at the feet.) Per staff R1 is not receiving hospice care. LPA noted two (2) mounted Fire Extinguishers that were last services on 07/24/2017. On 11/21/2024 and 12/10/2024, and 12/13/2024, LPA observed the following old furniture in the backyard; commodes, wheelchairs, hospital beds, mattresses and two old recliners. LPA also noted 2 staff rooms in the three car garage that are not on the displayed facility floor plan.
Based on the observations made on 11/21/2024, 12/10/2024 and 12/13/2024, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of LIC809, LIC809D, LIC9102 and Appeal Rights were sent to email on file.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2024
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 3
Document Has Been Signed on 12/13/2024 01:52 PM - It Cannot Be Edited


Created By: Lydia Martinez On 12/13/2024 at 10:04 AM
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
,
, CA

FACILITY NAME: PACIFIC VISTA SENIOR LIVING
FACILITY NUMBER: 331880572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2024
Section Cited
CCR
87465(h)(2)

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Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication. This requirement is not being met as evidenced by:
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Administrator agrees to secure all medication at all times. Administrator to read section cited, conduct in-service with staff and submit proof of understanding and training to LPA Lydia Martinez by 12/16/2024.
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Licensee failed to ensure medications are inaccessible to residents in care. On 11/21/24 & 12/10/24 & 12/13/2024, LPA observed Ziploc bag with 6 bottles of vitamins in kitchen refrigerator. This poses an immediate health and safety risk to residents in care.
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Type A
12/16/2024
Section Cited
CCR87203

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Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by:
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Administrator to immediately have the Fire Extinguishes serviced or replaced. Fire extinguishers are to be serviced annually. Submit proof of correction to LPA Martinez by 12/16/2023.
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LPA observed Fire Extinguishers mounted on the wall were last serviced on 07/24/2017. This poses an immediate Health & Safety risk to the 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:Marina Stanic
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/13/2024 01:52 PM - It Cannot Be Edited


Created By: Lydia Martinez On 12/13/2024 at 10:09 AM
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
,
, CA

FACILITY NAME: PACIFIC VISTA SENIOR LIVING
FACILITY NUMBER: 331880572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
87608(a)(5)(A)(B)

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Postural Supports: (a) Based on the individual's preadmission appraisal, and subsequent changes...Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports...(A) A bed rail that extends from the head half the length of the bed and...
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Administrator to remove the bed rails and/or obtain physician orders for the one half-bed rail if there is a need and submit proof to LPA Martinez 12/19/2024..
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(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care...This requirement was not met as evidenced by: Based on LPA’s observation, AD did not comply with the section cited in that R1’s bed has 3 half bed rails tied
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together with shoelaces, (2 half bed rails make a full bed rail and a half bed rail at the feet.) R1 is not receiving Hospice care. This poses a potential Health, Safety or Personal Rights risk to the resident in care.
Type B
12/16/2024
Section Cited
CCR87555(b)(26)

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General Food Service Requirements: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met at evidenced by:
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Defiency Cleared during visit. LPA observed plenty of food, including vegetables and fruits.
Administrator to ensure non-perishable and perishable food supplies will be replenished at all times.
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Based on LPA’s observation on 11/21/24 and 12/10/24, Licensee did not comply with the section cited in that there was not enough non-perishable and perishable food supply to sustain 7 days with 6 residents.
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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:Marina Stanic
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2024


LIC809 (FAS) - (06/04)
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