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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880893
Report Date: 05/10/2023
Date Signed: 05/10/2023 02:40:27 PM


Document Has Been Signed on 05/10/2023 02:40 PM - It Cannot Be Edited

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
, CA 92507



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: 95DATE:
05/10/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jennifer Heldoorn, Executive TIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility for a case management visit related to the passing of an adult resident (R1), who passes away on 04/29/2023. LPA Prieto met with Executive Director Jennifer Heldoorn and RSD Isabel Enriquez. LPA explained the purpose of the visit and gathered pertinent information related to R1s passing. LPA was provided with R1's ID/Emergency Information, Admission's Agreement, Physician's Report, Resident Appraisal, Needs and Services Plan, Progress Notes, Medication Records, Incident reports and a 30 day Notice from the family of R1.

R1 was visited by a family nearly everyday of R1's stay at the facility. Interviews and documentation will show that R1 last left the facility on 04/17/2023 for a routine Doctor's appoint. R1 was seen by PCP and later transferred to Loma Linda Medical Hospital under doctor's supervision. A 30 day Notice was given to Business Office Manager Michelle Sosa on 04/28/2023, indicating R1 is has a previous terminal illness and may pass under medical care. R1 passed at the medical facility, with facility and per a family directive.

LPA Prieto concluded interview with facility staff. LPA Prieto and Executive Director Jennifer Heldoom both signed this report and a copy was left with the facility.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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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