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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 01/09/2023
Date Signed: 01/09/2023 11:25:30 AM

Unfounded


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 18-AS-20220228114856
FACILITY NAME:PACIFICA SENIOR LIVING HILLSBOROUGHFACILITY NUMBER:
361880893
ADMINISTRATOR:JENNIFER HELDOORNFACILITY TYPE:
740
ADDRESS:11918 CENTRAL AVENUETELEPHONE:
(909) 548-2100
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:156CENSUS: 106DATE:
01/09/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jennifer Heldoorn Administrator TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Staff did not check on resident every 2 hours
Staff are not properly trained
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility for the purpose of delivering findings on the complaint(s) listed above. LPA met with Jennifer Heldoorn and she was informed of the purpose of the visit.

Allegation #1- Staff did not check on resident every 2 hours
During the visit LPA Allen observed several staff members walking throughout the facility checking on resident and asisiting them with activities and providing liquids to them. LPA Allen interviewed seven (7) staff members, reviewed Resident 1 (R1) file and there was no physician’s order stating that the resident had to be check on every two (2) hours.

Allegation #2- Staff are not properly trained.
LPA Allen interviewed Seven (7) staff members who stated training is done yearly which is computer based and documented once completed. LPA Allen also observed documentation that confirmed adequate training has been provided to staff members yearly or as needed.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2022
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-20220228114856
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
, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH
FACILITY NUMBER: 361880893
VISIT DATE: 01/09/2023
NARRATIVE
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Based on observation, record review and interviews conducted, the two (2) allegations listed above are Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

LPA Allen conducted an exit interview where this report was discussed with the Jennifer Heldoorn and a copy was provided with appeal rights at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2