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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 06/17/2020
Date Signed: 06/18/2020 08:04:46 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/16/2020 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200616132802
FACILITY NAME:PACIFICA SENIOR LIVING HILLSBOROUGHFACILITY NUMBER:
361880893
ADMINISTRATOR:TAYLOR, MANDYFACILITY TYPE:
740
ADDRESS:11918 CENTRAL AVENUETELEPHONE:
(909) 548-2100
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:156CENSUS: 137DATE:
06/17/2020
UNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Mandy Taylor, Executive DirectorTIME COMPLETED:
11:31 AM
ALLEGATION(S):
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Facility did not issue a refund.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone to commence a complaint investigation via telephone due to COVID-19. The LPA identified herself and discussed the purpose of the call and the elements of the allegation with Executive Director (ED), Mandy Taylor.

Pertaining to the allegation, "Facility did not issue a refund," is was alleged a pre-admission refund was requested for a perspective resident, Resident One (R1), in the amount of $3,000 on April 01, 2020, though it was not received. The LPA initiated the investigation into the allegation on June 17, 2020; staff interviews were conducted, records were reviewed and copies of pertinent information obtained. Staff interviews revealed the pre-admission refund request was received and later processed on April 03, 2020. According to staff interviews, refunds are submitted approximately thirty (30) days after the request is received. In addition, interviews and a facility refund statement indicated technical issues lead to the refund check being cancelled and a check not being mailed out. Email records, dated June 10, 2020, between facility staff show the request was submitted for a second time and reprocessed. According to ED Taylor, a check was sent out on June 15,
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
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-20200616132802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 HILLSBOROUGH
FACILITY NUMBER: 361880893
VISIT DATE: 06/17/2020
NARRATIVE
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 2020 in the amount of $3,500. Therefore, this allegation is deemed UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview was conducted with Claudia Ruiz, Business Office Manager, in which this report was reviewed and a copy provided.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2