331881073-4-22-2025-18-AS-KHEN-DG87M6-20250429214638

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881073
Report Date: 04/22/2025
Date Signed: 04/22/2025 05:23:57 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
11/18/2024 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 18-AS-20241118143654

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: 198	DATE:	04/22/2025
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Rance Leth, Executive Director		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff do not ensure that resident is sufficiently fed while in care
Staff do not respond to requests for assistance by resident in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit related to the allegations listed above. LPA initially met with facility staff and explained the reason for today’s visit. LPA met with Executive Director Rance Leth at 09:56AM. Entrance interview conducted.

During today's visit, LPA interviewed residents and staff between 09:25AM – 09:40AM and 10:17AM to 02:45PM and obtained and reviewed copies of relevant documents. During an initial complaint visit conducted by LPA Yolanda Delgado on 11/22/2024, LPA Delgado interviewed Business Office Manager, two (2) staff, one resident (1) requested and obtained copies of pertinent documentation. Throughout the course of the investigation, LPA Dulek reviewed all documents gathered and conducted additional staff interviews telephonically. The following was then determined:

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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-20241118143654

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: 04/22/2025

NARRATIVE

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Allegation: “Staff do not ensure that resident is sufficiently fed while in care:”

The complaint alleges that Resident #1 (R1) was not provided any meals on 11/16/2024. R1 stated on this date, they were experiencing leg pain and chose not to leave their room for meals. Interview with R1 revealed that there was a misunderstanding, and no complaint should have been filed. R1 indicated they are able to request meals in their room. However, at the time of the complaint, R1 did not request a meal, as R1 was not hungry. In another statement, R1 indicated they had slept through lunch and staff had brought her breakfast that day. Record review revealed that R1’s care assessment dated 10/27/2024, indicates meals – preparation only. According to staff interviewed, R1 prefers to stay in their room and requests meals be brought to their room. Occasionally R1 requests a staff escort to meals by pressing their pendant. Residents interviewed stated they receive all meals in the dining room daily or they can order with the staff and the meals can be delivered to their personal rooms. ED stated the dining room is open from 07:00AM to 06:00PM and residents can eat meals and/or snacks all day long. Care staff do have a checklist of their assigned residents and observe that their assigned residents attend meal service. If care staff do not see a resident at a meal, care staff will follow up with the resident to see if they would like to order a meal. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "staff do not ensure that resident is sufficiently fed while in care" is deemed UNSUBSTANTIATED at this time.

Allegation: “Staff do not respond timely to resident’s request for assistance:”

The complaint alleges that on 11/16/2024 R1 pushed their pendant and no staff came to assist. During initial visit, R1’s pendant was tested and staff responded in less than 2 (two) minutes. Interview with staff revealed that there are typically 4 (four) care staff assigned to assist Assisted Living residents during the day. Facility policy states that staff respond to pendants within 15-20 minutes. Interview revealed there are times when the care staff is busy assisting other residents and may take longer to respond, but they still do their best to remain within the appropriate time frame. Care staff also carry walkie talkies and can request another staff to assist if the assigned caregiver is busy assisting another resident. Pendant response system is computerized, however, record retention is for a 30-day period, so LPA was unable to review response records for the date in question. Residents interviewed felt their needs are being met and staff are timely in responding to

Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20241118143654

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: 04/22/2025

NARRATIVE

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requests for assistance. R1 stated the complaint should never have been filed and most staff assist R1 timely whenever possible. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the above allegation is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted with ED. A copy of today’s report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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