331881073-4-22-2025-18-AS-KBUY-DG8VPW-20250430163727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881073
Report Date: 04/22/2025
Date Signed: 04/22/2025 04:42:25 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
01/21/2025 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 18-AS-20250121133146

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:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident is reporting ring is missing

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/22/25 at 8:50 a.m. Licensing Program Analyst (LPA) Melisa Rankin and Kelly Dulek arrived to conduct an unannounced visit to the facility to deliver the findings of the investigation into the above allegations. The LPA met with Executive Director (ED), Rance Leth, and informed him of the purpose of the visit.

An initial visit on 01/27/25 by LPA Yolanda Delgado was conducted. LPA Delgado, conducted interviews, reviewed records and took copies of pertinent documentation.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
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 2

Control Number 18-AS-20250121133146

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On the allegation Resident is reporting ring is missing.
Complaint states that on 01/15/25 a caregiver was informed by a resident that a ring was missing from their room. Prior to arrival LPA Rankin interviewed the Responsible Representative (RR), called staff, and reviewed interview records from prior LPA visit as well as the documents collected during the initial visit. Review of these documents noted that Resident 1 (R1) and their RR signed the Resident Personal Property and Valuables (LIC 621) form, but did not list any property. R1 and RR also signed all appraisal, consent forms, and the admission agreement. On the admission agreement there is a theft and loss policy noted.

In response to the theft and loss policy the facility documented the allegation, submitted a report to the Ombudsman office, notified Community Care Licensing, and filed a police report. Additionally, the facility notified the RR.
LPA Dulek who conducted resident interviews during the visit stated 1 out of 6 residents interviewed stated they had missing items which the resident alleges occurred in the last 2 – 3 weeks, and LPA Rankin interviewed an additional 3 residents in which one stated they had missing items which occurred over 6 months ago. Staff 2 (S2) interviewed stated R1 is very private and meets staff at their door.

LPA interviewed the RR on 4/21/25. RR stated they had not seen the ring in question but did state at one point that the RR brought a box of jewelry to R1 at the facility. RR is unsure of how much or what specific items were in the box.
Due to R1 and RR not noting the property on the Resident Personal Property and Valuables (LIC 621) form and the facility following the theft and loss policy and based on interviews, and records reviewed. The allegations may have happened or is valid, but there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Copy of report printed and given to Licensee.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
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 2