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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880893
Report Date: 03/20/2024
Date Signed: 03/20/2024 01:33:04 PM


Document Has Been Signed on 03/20/2024 01:33 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: 122DATE:
03/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jennifer Heldoorn, Executive DirectorTIME COMPLETED:
01:40 PM
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Licensing Program Analysts (LPA) Javier Prieto conducted an unannounced visit to the facility for to initiate Case Management visit Health & Safety check. LPA Prieto identified himself and discussed the purpose of the visit with Jennifer Heldoorn, Executive Director. Clients in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA Prieto observed no health and/or safety hazards inside the facility. LPA Prieto inspected the outside perimeter of the facility and observed no health and/or safety hazards. It was observed to have sufficient staff present at the facility to provide care. LPA Prieto inspected the facility dining and kitchen area and found to be clean, sanitized and neat in order. The needs of the residents in care appear to be met during this inspection.

An exit interview was conducted where this report (LIC809) was discussed and provided to Jennifer Heldoorn, Executive Director
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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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