331881073-2-21-2025-18-AS-TDAN-DE82H8-20250224162420

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881073
Report Date: 02/21/2025
Date Signed: 02/21/2025 03:37:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2024 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20240815095433

FACILITY NAME:	PACIFICA SENIOR LIVING MENIFEE		FACILITY NUMBER:	331881073
ADMINISTRATOR:	LETH, RANCE		FACILITY TYPE:	740
ADDRESS:	28333 VALLEY BOULEVARD		TELEPHONE:	(951) 679-8811
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	220	CENSUS: 174	DATE:	02/21/2025
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Rance Leth, Executive Director		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff member caused an injury to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA Javina George made an unannounced visit to the facility to commence a complaint investigation in regard to the allegation noted above. LPA met with Executive Director Rance Leth and explained the purpose of the visit and the elements of the allegation. The allegation was investigated, which consisted of observations, interviews and records review.

On August 15, 2024, Community Care Licensing received a complaint alleging that a staff member caused an injury (bruising) to resident. It was further alleged that a staff member had grabbed Resident #1 (R1) by the wrist and pinched them. Prior to going out to the facility a file/records review was conducted which revealed the facility submitted an unusual incident/injury report on 08/13/24 reporting R1 to have unexplained bruising. LPA conducted interviews with R1 whom stated and re-enacted how they were grabbed by an unknown staff member and pinched, however did not think that the staff had intent to harm them. In addition, LPA observed for R1 to have a red and purple colored bruise on their left

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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-20240815095433

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING MENIFEE	FACILITY NUMBER: 331881073
	VISIT DATE: 02/21/2025

NARRATIVE

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wrist measuring about 3" wide. R1 is visually impaired and was unable to provide a description of the staff. Additionally, R1 stated that they do not feel the staff intentionally grabbed them, but it was more a training issue regarding proper lifting techniques. LPA conducted interviews with multiple staff members, who stated that they were not initially aware of the bruising.

However, staff verified that once they became aware of the bruising, they questioned R1 and R1 stated that they were grabbed by their wrist and pinched by an unknown staff. R1 is believed to have obtained the injury (bruise) on or around 8/7/24 or 8/8/24. On 08/16/24 facility staff were retrained on proper lifting and transferring post incident. Based on observations, interviews and records review the allegation of staff member caused an injury to resident is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred.

An exit interview was conducted and a copy of this report and LIC 811-confidential names list was reviewed and provided to Executive Director Rance Leth.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC9099 (FAS) - (06/04)

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