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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881073
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:00:51 PM

Document Has Been Signed on 04/28/2022 02:00 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, 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: 159DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rachelle Wheaton, Resident Care DirectorTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPA) Javina George made an unannounced visit to conduct a case management visit to follow up on a resident death. LPA met with Rachelle Wheaton, Resident Care Director and explained the purpose of today's visit.

During the visit LPA reviewed and collected pertinent documentation as well as conducted staff interviews in regards to the death of resident #1 (R1). LPA interviewed Resident Care Director for further information in regards to the death of R1 and the events that led up to R1's death.

LPA inquired about the cause of the death. A death certificate has not been issued at this time. Additionally, the preliminary cause of death is still being determined. LPA advised to send a copy of the death certificate to the regional office once received.

No deficiencies were cited during this visit, or health and safety concerns were observed.

An exit interview was conducted, a copy of this report, and confidential names list (LIC811) was provided to Rachelle Wheaton, Resident Care Director.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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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