Pacific Vista Senior Living 2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Administrator, Jamie Tang. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of five (5) resident bedrooms, two (2) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry room, and a patio and yard with sufficient seating and space for activities. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 107.4 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. The LIC 610, emergency disaster plan is maintained. There are no firearms at this home and no bodies of water observed. LPA began review of client records. six (6) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed client records to be available and complete. Continued on LIC 809-C. LPA began review of employee records- Three (3) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 07/30/2027. LPA observed personnel records to be available and complete. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen. Medications are centrally stored. There is a locked cabinet in the living room allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed did not match the ledger. A deficiency will be cited. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers were purchased on 12/31/2024. Fire drills are conducted quarterly at the facility with the last drill on 08/01/2025 . Based on the information received during this visit today in the areas reviewed, there is one deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809, LIC 809-C, LIC 809-D and Appeal rights report was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Administrator, Jamie Tang. The LPA informed the Administrator of the purpose for the visit. The inspection included the following: The facility consists of four (4) resident bedrooms, two (2) bathrooms, a kitchen and dinning area, a living room area, a garage and laundry area, and a patio and yard with sufficient seating and space for activities. There are no bodies of water located on the property. According to Administrator, no weapons are stored in the home. All outdoor and indoor passageways are kept free of obstruction and are free of debris and other trash. There are grab bars for each toilet, bathtub and shower used by residents. Resident showers have non-skid mats present. The home is maintained at a comfortable temperature for the clients. Water temperature measured 103.4 degrees F. Lighting in the kitchen and one of the bedrooms had a broken dimmer switch that made it difficult to turn on the lights and will need to be repaired. A citation will be cited. The home was kept clean and free of any odors. LPA began review of client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA began review of employee records- Three (3) records were reviewed. LPA reviewed employee records for first aid certification, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 07/30/2025. LPA observed the criminal record clearance or an exemption records was not kept with personnel files. Administrator stated they believed having Guardian clearance was sufficient enough. A technical assistance will be issued for the fingerprint clearance not accessible within a reasonable time. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals in the living room and and for sharps in the kitchen. LPA observed cleaning chemicals under a bathroom sink consisting of floor liquid cleaner and sprays. A citation will be cited. Medication- are centrally stored. There is a locked closet in the living room allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors were tested and found to be operational. LPA observed Fire extinguisher to be expired and needing service. A citation will be cited. The facility is conducting emergency disaster/fire drills quarterly; last done on 10/01/2024. Based on the information received during this visit today in the areas reviewed, there are deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. A plan of correction has been discussed and agreed upon with Administrator. An exit interview was conducted, and this report was discussed and provided to Administrator, Jaime Teng.the state’s words, verbatim · CDSS document, Nov 13, 2024

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Licensee, Jaime Teng, who was informed of the purpose of the visit. At time of visit there were (4) residents and one (3) staff present. The facility is a one story home with four (4) bedrooms and (2) bathrooms. No pools or fire arms are kept at the facility. The facility serves resident ages of 60 years and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations and hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. The facility's outdoor area was observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 106.8F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment. LPA observed the refrigerator in the facility kitchen to be taken out of its cavity with a tool box besides it. LPA was informed by staff that the freezer was currently not working. Technical advisory note was documented with licensee plan on repair and plan to ensure residents have required food available. LPA observed the food supply for the facility and observed it was within the required amounts. Record Review and Resident/Staff Files: LPA reviewed staff files and training that contained staff criminal clearance and updated training along with CPR/First Aid. The administrator has proof of submitting a recertification for Administrator certificate to the department. Resident files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All client medication was locked in living room cabinet. LPA reviewed client medications for residents and observed two (2) resident medications that were being kept in weekly pill boxes. This poses a potential risk for medication errors. LPA also found medication for one (1) resident was being stored on residents bedside table unlocked. This poses a potential risk for other residents to have access to the medication. These deficiencies were cited along and plan of correction was created with licensee. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. Technical advisory note was documented for licensee to updated their LIC610D to the meet department requirements. Licensee was given direction on where to find this information. LPA reviewed documentation showing last fire drill conducted 8/28/23. The licensee agreed to hold another drill by the end of the month. LPA observed all facility exits were clear from obstructions. An exit interview was conducted where a copy of this report, deficiency pages, and appeal rights were provided to Licensee, Jaime Teng.the state’s words, verbatim · CDSS document, Nov 20, 2023

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are not properly trained to meet resident needs.

Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the aleegation noted above. LPA met with Administrator Jamie Teng and explained the purpose of the visit. The allegation was investigated. The investigation consisted of observations, interviews and records review. It was alleged that on or around 8/3/23, Resident #1 (R1) was “acting erratically” which prompted 9-11 being called out to the facility. It was also alleged that the facility staff was unable to provide any information about R1’s health conditions, and nor could any of the staff could provide any answers to the questions that were asked pertaining to R1. Per an interview with R1’s responsible party due to R1 and their current state exhibited over the past month agreed that the home was not appropriate and did not want R1 to stay at the facility. LPA conducted a complaint visit on 8/8/23 and there was no training information available as the facility was reportedly converting to electronic files. LPA requested the training documentation. The training checklist were received and reviewed and the checklist for Staff #1 is altered. Substantiated Their form has white out with their name typed over it. It was further observed that the hours and signatures are the exact same. Per interviews with facility staff, the training received was from a personal experience from a family member and from working at another residential care for the elderly facility, prior to working at the facility. In addition per the Administrator Jamie Teng “the training dates are unknown as the training was completed prior to both Staff #1 (S1) and Staff #2 (S2) being hired”. Based on interviews the allegation of Staff are not properly trained to meet resident needs is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted and copy of this report, 9099D, and appeal rights were reviewed and provided to Jamie Teng, Administrator. R1 did not have a profile with medications on file with them. During the initial complaint visit conducted on 8/8/23, LPA did not observe a facility file nor documents, to confirm which medications R1 was prescribed. However, it was confirmed that R1 was discharged from the SNF to the facility, but no confirmation that R1’s medication was sent over to the pharmacy. Additionally, there was no other explanation provided from the Administrator Jamie, other than “no R1 was not given any medication at the facility as they were not a resident". Therefore, the allegation of staff failed to administer residents medication as prescribed is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted and a copy of this report, and appeal rights were provided to Administrator Jamie Teng.the state’s words, verbatim · CDSS document, Oct 5, 2023 · control 18-AS-20230803125541

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 20, 2023

87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering and maintenance of buildings, equipment grounds... This requirement is not met as evidenced by: The licensee failed to ensure staff were properly trained to provide care and supervision to R1, 2 out of 2 times. This poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: The licensee agrees to retrain both S1 and S2 with the training listed on the staff training checklist. Proof of completed POC is due by 5pm on 10/20/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Javina George made an unannounced case management deficiencies visit as LPA was delivering findings for complaint control # 18-AS-20230803125541 and observed the following deficiencies. The facility admitted (accepted responsibility) for Resident #1 (R1) on or around August 3, 2023. Per interviews with Administrator Jamie Teng, there is a contract or agreement with a local skilled nursing facility (SNF) to discharge residents from the SNF to the facility. Due to this contract or agreement, the facility is accepting residents without properly screening them, as well as not completing the evaluation of suitability for admission. The evaluation consist of: (1) Conduct an interview with the applicant and his responsible person. (2) Perform a pre-admission appraisal. (3) Obtain and evaluate a recent medical assessment). Per an interview with Administrator Jamie, the LIC 602 (Physician's report) was requested but was never sent over. As a result of the facility not properly screening new residents. R1 was admitted to the facility and began exhibiting erratic behaviors by trying to hurt thyself. As a result the facility had to contact 9-11 to assist, and have R1 removed without returning to the facility. Further interviews conducted with R1's responsible party who deemed the facility was not suitable for R1 and they should have not been sent there due to their current mental state that R1 had been exhibiting for the past a couple of months. Additionally, LPA observed that when LPA requested the staff files for review from the Administrator Jamie Teng. Jamie stated that the facility was in the process of converting to electronic files. Jamie verbally provided Staff #1 (S1) and Staff #2 (S2) hire dates. In addition to Administrator Jamie provided a copy of the staff training checklist that was the exact same, however S2’s name is written over S1’s name that had been covered with white out. The hours are off center and the exact same hand writing. Interviews with S1 and S2 stated that they both received training prior to working at the facility. Not only did the Administrator make false claims but provided false training documents and is being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8) on the attached 809D. An exit interview was conducted and a copy of this report, and appeal rights were reviewed and provided to Administrator Jamie Teng.the state’s words, verbatim · CDSS document, Oct 5, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87456(a)(1-3) · Plan of correction due date: Oct 20, 2023

87456 Evaluation of Suitability for Admission (a)(1-3) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (1) Conduct an interview with the applicant and his responsible person. (2) Perform a pre- admission appraisal. (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: The licensee failed to conduct an evaluation for R1, 1 time. This posed a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: The licensee agrees to submit a personal statement self certifying that any new residents moving forward the facility will conduct an evaulation of suitability.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87207 · Plan of correction due date: Oct 20, 2023

87207 False Claims No licensee, officer or employee of a license shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: 2 out of 2 times the licensee stated that their staff received training upon hire. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: The licensee agrees to make a personal statement of understanding about the importance of providing true and accurate information to the department, The statement is to include the potential risks and consequences of providing misleading/false claims, or statements. Proof is to be submitted to the department by 5pm on the due date indicated.