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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880893
Report Date: 08/13/2020
Date Signed: 08/13/2020 10:39:13 AM

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 HILLSBOROUGHFACILITY NUMBER:
361880893
ADMINISTRATOR:TAYLOR, MANDYFACILITY TYPE:
740
ADDRESS:11918 CENTRAL AVENUETELEPHONE:
(909) 548-2100
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:156CENSUS: 128DATE:
08/13/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Mandy Taylor, Executive DirectorTIME COMPLETED:
09:27 AM
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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone to commence a case management televisit due to COVID-19. The LPA identified herself and discussed the purpose of the call with Executive Director (ED), Mandy Taylor.

The Department received an Unusual Incident Report (UIR) on August 04, 2020 pertaining to Resident One (R1). The UIR detailed the attempted suicide of R1 on July 30, 2020 at approximately 9:00 PM. The report details staff, during a routine check, observing R1 to be cutting into their left wrist with scissors and a butter knife.

On this visit the LPA conducted staff interviews and, assisted by Taylor, toured the bedroom of R1. According to Taylor, the resident had no history of self harm or suicidal behavior and the resident's medical assessment noted no diagnosis of cognitive disease. Interviews reported discussion with R1's responsible party and a staffing service was conducted and a personal caregiver was arranged for R1 by the time they were discharged back to the facility on August 05, 2020. The LPA will review reports received from the facility and follow-up if necessary. No health and safety concerns were observed on this televisit.

An exit interview was conducted with ED Taylor via telephone and a copy of this report was provided to Taylor via email. Report with facility representative signature was obtained.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2020
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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