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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 04:31:12 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
09/07/2022 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 18-AS-20220907084531
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:
05:00 PM
ALLEGATION(S):
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Resident is not provided a sanitized foley bag.
Resident was left soiled for an extended period of time.
INVESTIGATION FINDINGS:
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On 4/22/25 at 8:50 a.m. Licensing Program Analyst (LPA) Melisa Rankin arrived to conduct an unannounced visit to the facility to investigate and deliver the findings regarding the above allegations. The LPA met with Executive Director (ED), Rance Leth, and informed him the purpose of the visit.

An initial visit on 9/14/22 by LPA Stephanie Torres was conducted. LPA Torres conducted staff interviews, reviewed records, and took copies of pertinent documentation.

On the allegations Resident is not provided a sanitized foley bag and Resident was left soiled for an extended period of time.


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-20220907084531
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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Complaint states the resident presented at the emergency room on 9/3/22 with Foley Catheter pulled out, but a portion still inserted into R1 and that the foley bag was not appropriately placed, was unclean and open to infection. In addition, the resident was covered in feces.

Prior to the visit LPA Rankin reviewed staff interviews provided by prior LPA Torres, as well as contacted additional staff interviews via phone calls. Interviews of facility staff done by both LPA’s, as well as records obtained showed R1 had been re-admitted to the facility approximately late afternoon of 9/2/22 after being discharged from a Skilled Nursing Facility (SNF), and all staff interviewed stated, that on the morning of 9/3/22 R1 had either driven over or cut their catheter that was connected to the foley bag causing it to be disconnected. Urine was dripping from the tube which was being dragged around the floor behind R1’s scooter.

Staff interviewed and records reviewed stated that R1 was not acting in their usual character, R1 was in the lobby without their shirt, and was slurring words, R1 was confused, and when staff went to R1’s room they smelled urine and noticed feces. Staff called 911 to have R1 transferred due to the foley cather bag needing to be repaired, and the residents change in behavior. Records review showed that R1 had a UTI when admitted to the hospital. The time frame for R1’s stay at the facility was less than 24 hours. R1 was discharged on 9/2/22 from the SNF and the resident was sent out the early afternoon of 9/3/22 from the facility.

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