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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881073
Report Date: 05/19/2021
Date Signed: 05/20/2021 11:30:30 AM

Document Has Been Signed on 05/20/2021 11:30 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 MENIFEEFACILITY NUMBER:
331881073
ADMINISTRATOR:LETH, RANCEFACILITY TYPE:
740
ADDRESS:28333 VALLEY BOULEVARDTELEPHONE:
(951) 679-8811
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY: 220CENSUS: 158DATE:
05/19/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rance Leth - Administrator/Executive DirectorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility for the purpose of conducting a Pre-Licensing inspection. LPA Colvin met with Executive Director/Administrator Rance Leth and toured the facility. Fire Clearance was granted for 220 non-ambulatory residents on 3/17/21. LPA Colvin toured the facility and the following was observed:

The property consists of one building for Assisted Living residents and a secured wing for Memory Care, which includes a delayed egress. Resident suites consist of shared and private suites, with each suite having a private bedroom and shared bathroom. LPA Colvin tested the hot water two resident bathrooms and the staff break room, and observed the water temperature to reach 109 degrees. Pool and spa on site are in a fenced area which is inaccessible to Memory Care residents. All suites are furnished according to regulation. Fire extinguishers are located throughout the facility and are fully charged.

LPA Colvin observed the main kitchen to be clean and sanitary with operable appliances. Memory Care has a smaller for holding prepared food for each meal. Facility was observed by LPA to store food in a safe and healthful manner, and has a sufficient supply for 2 days of perishable food, and a 7 day supply of non-perishable food items. The emergency disaster plan, personal rights and complaint procedures are posted throughout the facility. The facility has stocked first aid kits in their Wellness Center, along with a minimum of 30-day supply of PPE. Cleaning supplies and toxins were inaccessible and kept in locked storage. Resident files are kept in an electronic form as well as a hard copy form and are kept in each cottage. Facility has an emergency exit plan in place an posted in plain view at the facility, along with operational smoke detectors and carbon monoxide detectors, as well as multiple fire extinguishers. The administrator's certificate is current and expires in 2022. No deficiencies were observed during this visit.

An exit interview was conducted where this report was provided to Administrator Rance Leth.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2021
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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