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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881073
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:21:45 PM

Substantiated


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
06/26/2024 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240626140848
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: 210DATE:
02/25/2025
UNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Executive Director, Rance LeithTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff do not ensure medications are dispensed as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegation. LPA met with Executive Director, Rance Leith, who was informed of the purpose of the visit. The investigation consisted of interviews and records review.

It was alleged that “Staff do not ensure medications are dispensed as prescribed” It was alleged Resident#1 (R1) did not receive their PRN medication as prescribed June of 2024. Interview with R1 was unable to be conducted as R1 has since passed away. Interview with R1’s responsible party revealed they were unaware of any medication errors or PRN medication not being given as prescribed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 18-AS-20240626140848
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: 02/25/2025
NARRATIVE
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Records review revealed no incident reports for medication errors for R1 were documented. Electronic Medication Administration Record (EMAR) for R1 June 2024 revealed R1 had PRN medication prescribed to them which was recorded as given with the reason for giving the medication and the effectiveness of the dose recorded.

Interview with (4) med tech staff revealed they were not aware of any medications errors for R1 and stated R1 obtained their PRN medication when needed.

It was also alleged Resident #2 (R2) was given their medication twice May or June of 2024.

Incident report dated 05/25/2024 revealed R2 was given Medication #1 (M1) twice due to a documentation error. The incident report stated Staff #1 (S1) had given Medication #1 (M1) at 6:00am to R2 and did not document it on the MAR before ending their shift. Another staff gave M1 to R2 after seeing M1 was not documented as given. The resident was placed on alert charting and monitored for any change in condition.

Interview with S1 revealed they forgot to document M1 as given to R2 and another staff had given M1 again to R2 due to seeing M1 was not documented.

An interview with R2 was unable to be conducted as R2 has since passed away. Interview with R2’s responsible party revealed there was an incident where R2 received M1 twice due to a staff member not properly recording the medication as given. The responsible party stated they were informed of the error and the resident did not suffer any adverse reactions.

Therefore, based on LPA’s interviews conducted, and records reviewed the allegation that residents did not get their medication dispensed as prescribed is found to be substantiated for R2's medication error. The preponderance of the evidence standard has been met, therefore the above allegation is found to be substantiated at this time. California Code of Regulations Title 22 is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
06/26/2024 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20240626140848

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: 210DATE:
02/25/2025
UNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Executive Director, Rance LeithTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff allow residents to be left in soiled clothing for extended periods of time
Staff do not ensure facility is kept free of mal odors
Staff do not ensure resident records are properly maintained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to investigate the above allegations. LPA met with Executive Director, Rance Leith, who was informed of the purpose of the visit. The investigation consisted of interviews and records review.

It was alleged “Staff allow residents to be left in soiled clothing for extended periods of time”, regarding R1 being left unchanged with soiled clothing, sheets, and diaper during the facility’s NOC shift around June of 2024. It was alleged “Staff do not ensure facility is kept free of mal odors” regarding R1’s room smelling of feces and urine due to not being changed for an extended period of time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20240626140848
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: 02/25/2025
NARRATIVE
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June 2024 Staff Schedule and staff interviews revealed the NOC shift is from 10:00pm to 6:00am and is followed by the AM shift from 6:00am to 2:00pm. Staff interviews revealed residents are checked on every (2) hours unless they require additional checks per their incontinent needs and written assessment. R1’s Resident Assessment dated 06/18/2025 revealed R1 required to be checked on (4) times per shift, which equates to every (2) hours. Staff revealed changing of residents is not documented.

An interview with R1 was unable to be conducted as R1 has since passed away. Interview with R1’s responsible party revealed they visited R1 around June of 2024 in the early morning and stated R1 was observed in soiled diaper and clothing occasionally. The responsible party estimated that R1 had not been change in (4) hours. They reported R1’s room was not observed to smell of urine or feces.

Interview with (2) NOC shift staff working June of 2024 revealed R1 was never left in soiled clothing or diaper and could not recall a time where R1’s room smelled of feces or urine.

LPA interviewed (3) AM shift staff working June of 2024 which revealed conflicting information. (1) staff interview revealed they were unaware of R1 being left in soiled clothing or diaper for an extended period of time or R1’s room being malodorous. (1) staff interview revealed they observed R1 in soiled clothing, sheets, and diaper and R1’s room was malodorous. This staff stated they reported this to the facility nurse Staff #2 (S2). Interview with S2 revealed they did not recall a time when R1 was left in soiled clothing or diaper.

Therefore, the allegation that R1 was not changed for an extended period of time and that R1’s room was malodorous is found to be unsubstantiated.

It was alleged “Staff do not ensure resident records are properly maintained” It was alleged that the narcotic medication counts for residents were not accounted for and the medication log for narcotic medication was being altered by staff June of 2024.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 18-AS-20240626140848
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: 02/25/2025
NARRATIVE
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LPA conducted interviews with (4) residents who resided at the facility June of 2024. The residents revealed they were unaware of the medications they were taking or if there were any medication errors with narcotic medications. LPA conducted (2) interviews with responsible parties for residents who resided at the facility June of 2024 who revealed they were unaware of any narcotic medication errors.

LPA conducted interviews with (4) med tech staff who worked at the facility June of 2024. Staff interviews revealed narcotic medications are counted by med tech staff every shift and are recorded in the Electronic Medication Administration Record (EMAR) system by the supervising nurse in a narcotics medication Shift Change Log. Staff revealed the EMAR system accounts for any changes or edits made and were unaware of the logs were being altered. Interview with supervising nurse from June of 2024 denied the narcotics medication Shift Change Log was altered and stated all narcotics were accounted for.

LPA requested the EMAR Narcotic log for (4) resident who resided at the facility June of 2024. The logs revealed the medication was accounted for every day of June 2024 with no discrepancies or documented changes.

Therefore, the allegation that staff are not ensuring the resident’s medication records are maintained is found to be unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20240626140848
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2025
Section Cited
CCR
87465(a)(4)
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(a) A plan for incidental medical...care shall be developed by each facility. The plan shall encourage routine medical...care and provide for assistance in obtaining such care... (4) The licensee shall assist residents with self-administered medications as needed.
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The Administrator agreed to send medication training for S1 by the POC due date.
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This requirment was not met as evidenced by: Based on interview and record review, R2 received incorrect does of M1 due to staff error. This posed a potential health, safety or personal rights risk to 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.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6