336425840-8-4-2021-18-AS-CCON-C5KRF7-20210804125840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336425840
Report Date: 08/04/2021
Date Signed: 08/04/2021 12:58:46 PM

Document Has Been Signed on 08/04/2021 12:58 PM - 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: 110		CENSUS: 80	DATE:	08/04/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Eva Tawfik - Executive Director/Administrator		TIME COMPLETED:	12:00 PM

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) Colvin made an unannounced visit to the facility in order to follow up on a recent incident that the facility self-reported to Community Care Licensing. LPA Colvin met with Administrator Eva Tawfik and informed her of the purpose of today's visit to the facility. On 7/29/21, memory care resident (R1) jumped the patio wall (exiting the facility) and walked into traffic. LPA Colvin reviewed R1's chart, interviewed Administrator Eva Tawfik and Residents Services Director (RSD)_, and toured the back patio where R1 AWOL'd from. Administrator Eva Tawfik informed LPA Colvin that R1 is mobile and able to walk around the gated areas of the facility, and that on the date of the incident, a staff member (S1) observed R1 to have taken a wooden board from an undetermined location, and to have propped it up against the brick wall (which separates the backyard from the outside of the facility) and used it to climb the fence. According to the Administrator, S1 and other on-site staff immediately followed R1 for safety, and when unable to convince R1 to return to the facility with them, 911 was called and R1 was placed on a psychiatric hold. Eva confirmed that while on the hold, R1's medications were adjusted and there have been no additional problems with R1 since. LPA Colvin reviewed the file and staff charting for R1 and observed R1 to be diagnosed with Alzheimer's/Dementia, and with behavioral issues noted from R1's physician regarding sun downing behavior and wandering (walking mostly). This was additionally noted in the facility's evaluation of R1, and it had been determined that R1 required additional status checks (4x per shift), though he scored minimally in the Psychological/Mental section of the facility's evaluation. In the staff charting for the month for July 2021, LPA Colvin observed that R1 began displaying exit-seeking behaviors on 6/2/21, which staff immediately addressed with R1's family and doctor, and R1 was prescribed additional medication. On 7/28/21, the day before the incident, R1 was noted by staff to have attempted to jump the wall, which was witnessed by staff. Staff contacted R1's family who stated that they would be sending an urgent message to R1's doctor for possible additional medication, which had previously been discussed.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

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: 08/04/2021

NARRATIVE

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LPA Colvin interviewed the MCD regarding R1's previous attempts to exit the facility, as well as inquired about if the facility contacted R1's doctor (in addition to R1's family contacting Dr), in order to insure the additional medication & treatment could be prescribed in a timely manner. The MCD stated that the facility was having R1's family communicate with R1's doctor, and that the family would forward the facility proof of communication. MCD additionally informed LPA Colvin that on the date that R1 left the facility, R1's daughter had a telephone call appointment that morning with R1's doctor, at which time the family obtained a prescription for additional medication for R1.

LPA Colvin toured the back patio and back yard where R1 had climbed the brick wall and left the facility on 7/29/21. The MCD was able to point out to LPA Colvin where R1 was seen running across a barren field that neighbors that side of the facility, and explain to LPA Colvin the progression of events in which MCD and S1 followed R1 to keep R1 safe, and eventually contacted police due to R1 continuing to wander into the street, where MCD and S1 were having difficulty keeping R1 safe from the traffic. LPA Colvin carefully examined the brick wall and observed for it to be approximately six feet tall. MCD confirmed that R1 was observed by S1 to have used a piece of wood to climb up the wall to be able to pull himself over. MCD is unsure of where the piece of wood came from, or how R1 obtained it. LPA Colvin confirmed that facility staff took appropriate measures to try to ensure R1's safety by communicating observations of wandering/exit-seeking behavior to family (and thereby physician), obtain additional medical assistance (medication), and provide supervision of R1 which enabled staff to witness R1's leaving of the facility and then following R1 and calling 911 for safety purposes. LPA Colvin additionally notes that the staff charting stated that when R1 returned to the facility from his psychiatric hold, R1 had a private caregiver to aid with providing additional supervision of R1. Additionally, Administrator Eva Tawfik informed LPA Colvin that the corporate office is looking into possibly increasing the height of the perimeter walls to try to provide additional safety measures to prevent another incident like this occurring.

An exit interview was conducted with Administrator Eva Tawfik and LPA Colvin advised her of her findings. A copy of this report was printed and provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021

LIC809 (FAS) - (06/04)

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