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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881073
Report Date: 04/22/2025
Date Signed: 04/22/2025 05:51:15 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
11/29/2023 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 18-AS-20231129162111
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: 198DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Rance Leth, Executive DirectorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff do not treat resident with dignity and respect
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 6 (six) residents and 6 (six) staff between 09:25AM – 09:40AM and 10:17AM to 02:45PM, interviewed R1’s private caregiver, interviewed R1’s family member telephonically and obtained and reviewed copies of relevant documents. During an initial complaint visit conducted by LPA Cheryl Goodrich on 12/06/2023, LPA Goodrich toured the facility, interviewed residents and staff, and collected pertinent documents. During a subsequent complaint visit conducted by LPA Kathleen Banrasavong on 03/27/2024, LPA conducted a tour, reviewed and obtained documents, and interviewed residents and staff. Throughout the course of the investigation, LPA Dulek reviewed all documents gathered. The following was then determined:
Report Continued on LIC 9099-C
Substantiated
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)
Page: 1 of 5
Control Number 18-AS-20231129162111
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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The complaint alleges that Staff #1 (S1) bullies Resident #1 (R1) in an “angry way.” Reporting party indicated that after discussing the concerns about R1 to S1’s supervisor, S1 was not to provide care to R1 any longer, however S1 continued to enter R1’s room and demanded R1 shower. LPA reviewed R1’s care plan and physician’s report, both of which indicate R1 requires assistance with activities of daily living (ADLs) including assistance washing R1’s hair and body, assistance with dressing and grooming. R1’s care plan does indicate bathing on pm shift with a note indicating “7PM. Would like 3 showers weekly.” LPA Dulek interviewed staff related to the allegation. Staff indicated there is a shower schedule and the care staff provide showers per the schedule. S1 works the pm shift, so S1 would have been responsible for showering R1 at times. Staff interviewed stated that many care staff, including S1 talk to R1 regularly and share personal information with R1. At the time of the complaint and ongoing since, staff have continued to share information with R1 and have had personal disputes amongst the staff, which have been discussed with R1. Management is aware of the ongoing concern and have held meetings addressing professionalism in the workplace. Staff interviewed have heard from residents that staff have been rude towards the residents, including R1. 4 (four) of 6 (six) residents interviewed indicated that there have been staff in the past around the time of the complaint as well as current staff that have yelled and been intimidating towards the residents. Based on interview and record review, the preponderance of evidence standard has been, therefore the allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (refer to LIC9099-D).

Exit interview conducted, appeal rights discussed, and a copy of this 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)
Page: 2 of 5
Control Number 18-AS-20231129162111
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: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidenced by:
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Executive Director agreed to conduct a vendorized training with all staff related to personal rights of residents. A copy of the training documents including trainer, date, staff sign in and materials will be submitted to CCL by POC due date.
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Based on interview, the licensee did not comply with the above cited section as 4 of 6 residents interviewed and staff corroborated that staff share personal information with residents and staff are rude to residents which poses a potential personal rights risk to persons 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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/29/2023 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 18-AS-20231129162111

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: 198DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Rance Leth, Executive DirectorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff dispensed medication that was not prescribed to resident
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 6 (six) residents and 6 (six) staff between 09:25AM – 09:40AM and 10:17AM to 02:45PM, interviewed R1’s private caregiver, interviewed R1’s family member telephonically and obtained and reviewed copies of relevant documents. During an initial complaint visit conducted by LPA Cheryl Goodrich on 12/06/2023, LPA Goodrich toured the facility, interviewed residents and staff, and collected pertinent documents. During a subsequent complaint visit conducted by LPA Kathleen Banrasavong on 03/27/2024, LPA conducted a tour, reviewed and obtained documents, and interviewed residents and staff. Throughout the course of the investigation, LPA Dulek reviewed all documents gathered. 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)
Page: 4 of 5
Control Number 18-AS-20231129162111
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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The complaint alleges that R1 was given a pill, which R1 did not recognize and caused R1 to become tired and lowered R1’s heartrate. R1 questioned Staff #2 (S2) about the unrecognized medication, but S2 indicated the medications were all correct. LPA reviewed R1’s Medication Administration Record (MAR) and cross referenced R1’s physician’s ordered medication list. LPA confirmed that all medications listed on the MAR have been ordered by R1’s physician. R1’s physician’s report does indicate R1 was able to store and administer their own prescription and PRN medications, however R1’s care plan indicates R1 was on medication management at that time. R1 and their family member stated R1 was taken to the hospital as a result of low heart rate. LPA reviewed incident reports for the time frame referenced in the complaint, but no incident reports were submitted relating to R1 being hospitalized, nor were there any care notes entered or other documentation to reflect outside care was needed. Interview with S2 revealed that R1 did not ask about their medications during the time of the alleged error and all medications were administered to R1 as prescribed. All other residents interviewed indicated their medications are administered on time and as prescribed. LPA confirmed R1 is no longer on medication management with the facility and is instead storing their own medications at this time. 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 is deemed UNSUBSTANTIATED at this time.

No citations issued related to the above allegation. Exit interview conducted. 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)
Page: 5 of 5