336425840-7-2-2021-18-AS-CCON-C4JPQV-20210702113147

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425840
Report Date: 07/02/2021
Date Signed: 07/02/2021 11:31:57 AM

Document Has Been Signed on 07/02/2021 11:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	PACIFICA SENIOR LIVING RIVERSIDE		FACILITY NUMBER:	336425840
ADMINISTRATOR:	EVA TAWFIK		FACILITY TYPE:	740
ADDRESS:	6280 CLAY STREET		TELEPHONE:	(951) 360-1616
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY: 92		CENSUS: 77	DATE:	07/02/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Eva Tawfik - Executive Director/Administrator		TIME COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) Crystal Colvin conducted an unannounced case management visit in order to increase the capacity per licensee request. LPA Colvin met with Executive Director/Administrator Eva Tawfik and explained the purpose of the visit. Licensee requested for a capacity increase from 92 residents to 110 residents, which includes an increase from 10 bedridden to 15 bedridden, and all residents able to be non-ambulatory. A Fire Clearance was approved on 7/29/20 for 95 non-ambulatory residents and 15 bedridden residents, for a total of 110 residents. Facility sketch on file shows sufficient square feet in the facility and activity rooms to accommodate the requested capacity. LPA Colvin went over the facility sketch with Administrator Eva Tawfik as well as the proposed changes to the capacity of the individual residential buildings/cottages (6 in total). The capacity increase is stemming from changing several single occupant bedrooms to shared bedrooms. The changes include the following: · Cottage 1 to increase capacity from 14 to 16 residents (2 single rooms changing to shared) · Cottages 2/3 increase capacity from 31 to 36 residents (5 single rooms changing to shared) · Cottage 4 increase capacity from 14 to 17 residents (3 single rooms changing to shared) · Cottage 5 increase capacity from 14 to 20 residents (6 single rooms changing to shared) · Cottage 6 increase capacity from 19 to 21 residents (2 single rooms changing to shared) LPA Colvin toured all residential buildings and visually inspected the proposed shared rooms. LPA Colvin confirmed that all identified shared rooms are large enough to accommodate the required furniture for two residents without inhibiting movement into and throughout the rooms. LPA Colvin additionally confirmed that there are sufficient bathrooms in the facility and each residential cottage to meet Title 22 requirements for ratio of residents to bathrooms.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING RIVERSIDE	FACILITY NUMBER: 336425840
	VISIT DATE: 07/02/2021

NARRATIVE

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The physical plant is ready for increase in capacity. LPA will submit file for capacity increase approval. The final approval of capacity increase is contingent upon Licensing Program Manager's (LPM's) final file review. Licensee will be notified by LPA once capacity increase has been approved by licensing. If capacity increase is approved, new license will follow in the mail after phone/email notification by LPA with Licensee.

Administrator Tawfik additionally inquired to LPA Colvin about an increase in Hospice patients allowed at the facility, after the increased capacity takes affect. LPA Colvin informed Tawfik that the facility will have to submit a request to Community Care Licensing for a Hospice Waiver Increase prior to being approved to have more than the approved amount of Hospice residents (28) at the facility. Request can be emailed, faxed, or postal mailed to the Riverside Community Care Licensing Adult and Senior Care Office.

An exit interview was conducted where this report was discussed, and a copy was provided to Executive Director/Administrator Eva Tawfik.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC809 (FAS) - (06/04)

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