<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 03/07/2023
Date Signed: 03/07/2023 12:30:08 PM

Unsubstantiated


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
01/05/2022 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220105125419
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: DATE:
03/07/2023
UNANNOUNCEDTIME BEGAN:
11:07 AM
MET WITH:Jennifer HeldoornTIME COMPLETED:
12:03 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not allowing resident access to their records.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced subsequent visit to continue the complaint investigation of and deliver findings on the above allegation. LPA met with business office manager Michelle Sosa who was informed of the reason for the visit. Executive director (ED) Jennifer Heldoorn met with LPA. Staff interviews and records review were conducted during today's visit.

It is alleged that the Facility is not allowing resident (R1) access to their records. On 12/14/21, R1 authorized party (AP) submitted a request for R1's records. Records revealed that on 12/21/21 ED spoke with AP and confirmed that R1 moved out of the facility in June 2021. Records reviewed show that on 12/21/22 AP sent a copy of the original records request to the business office manager (BOM) after ED and AP spoke on 12/21/21. On 12/23/21, R1's authorized party and BOM were in communication regarding specific files that AP requested. LPA reviewed records that show on 12/23/21 BOM reached out to the facility's in-house counsel for instruction and approval. On 12/29/21, facility counsel responded to BOM stating that counsel will need to review R1's file before producing a copy for AP. On 1/11/22, BOM received approval from facility counsel to provide a copy to
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
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-20220105125419
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: 03/07/2023
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
26
27
28
29
30
31
32
AP and AP received R1's records on 1/12/22. This allegation is therefore unsubstantiated.

A finding that the complaint in UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with and a copy of this report was to provided ED.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2