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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 03/25/2024
Date Signed: 03/25/2024 04:07:51 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/04/2020 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200804144941
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: 123DATE:
03/25/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Resident Services Director, Isabel EnriquezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not administer resident’s medication
INVESTIGATION FINDINGS:
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On 3/25/2024, Licensing Program Analyst (LPA), Janette Romero conducted an unannounced visit to the facility to deliver the findings of the investigation into the allegation noted above. LPA met with Resident Services Director, Isabel Enriquez who was informed of the purpose of the visit.

It was alleged, “Staff did not administer resident’s medication”, LPA reviewed Resident #1’s (R1’s) Needs and Services Plan dated 2/22/2019, which noted R1 required total assistance by medication technicians for medication administration. The Plan also indicated staff were to provide total assistance by ensuring staff would: remain with the resident until the medications had been taken, medications were not left unattended, medications were documented, report to the physician any missed doses or resident refusal of medication, report any changes in condition to physician and following any orders.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 548-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
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 5
Control Number 18-AS-20200804144941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH
FACILITY NUMBER: 361880893
VISIT DATE: 03/25/2024
NARRATIVE
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LPA reviewed R1’s July 2020 Medication Administration Record along with R1’s medication list which revealed no documented resident refusals of medications or missed doses. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was reviewed and provided along with Confidential Names List (LIC811).
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 548-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/04/2020 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200804144941

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: 123DATE:
03/25/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Resident Services Director, Isabel EnriquezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Resident sustained injuries while in care
Staff did not provide adequate food service
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Janette Romero conducted an unannounced visit to the facility to deliver the findings of the investigation into the allegations noted above. LPA met with Resident Services Director, Isabel Enriquez who was informed of the purpose of the visit.

Regarding the allegation, "Resident sustained injuries while in care," it was alleged Resident 1 (R1) sustained a bruise to their forehead, as well as two (2) black eyes on or around July 23, 2020. The cause of the injuries is unknown. The Department initiated the investigation on 8/6/2020 and records were requested and obtained. Staff and resident interviews were also conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 548-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200804144941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH
FACILITY NUMBER: 361880893
VISIT DATE: 03/25/2024
NARRATIVE
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One (1) of six (6) interviews conducted reported that R1 had been found on 7/24/2020, around 12:00 p.m., with injuries to their head and was subsequently sent to the hospital. One (1) of six (6) interviews conducted reported R1 was found in their bed, soaked in urine, with a bruise to their eye, which was swollen to the size of a golf ball. Staff interviews revealed no falls had been reported prior to the discovery of the resident. Records reviewed failed to show a record of any fall prior the incident on 7/24/2020. Medical records were requested and obtained; an American Medical Response (AMR) report revealed emergency personnel arrived to the facility at 11:52 A.M., and observed R1 with a, "large hematoma over left eye with ecchymosis left eyelid". The Discharge/Transfer Documentation report revealed R1 was admitted to Pomona Valley Hospital on July 24, 2020, and diagnosed with Blunt Head Trauma and Traumatic Orbital Hematoma.

Regarding the allegation of, “Staff did not provide adequate food service”, LPA reviewed R1’s Needs and Services Plan dated 2/22/2019, which noted R1 required meal reminders. One (1) of six (6) interviews conducted revealed R1 was able to eat on their own if facility staff provided R1 with a meal in R1’s bedroom. One (1) of six (6) interviews conducted revealed facility staff frequently required reminders to provide R1 with a meal and witnessing facility staff rushing to put meals together to provide for R1 because they had forgotten to distribute R1’s meals.

Based on LPA’s interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations (Title 22, Division 12, Chapter 1), are cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided along with Confidential Names List (LIC811) and Appeal Rights.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 548-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200804144941
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH
FACILITY NUMBER: 361880893
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Licensee stated the facility will conduct an in-service training regarding resident care and supervision and provide LPA with a copy of the sign in sheet by close of business on POC due date.
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During investigation of a complaint, LPA found that R1 sustained injuries while in the facility's care. This poses a potential health and safety risk for residents in care.
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Type B
04/04/2024
Section Cited
CCR
87464(f)(3)
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(f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily... This requirement was not met as evidenced by:
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Licensee stated the facility will conduct an in-service training regarding food service and provide LPA with a copy of the sign in sheet by close of business on POC due date.
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During investigation of a complaint, LPA found that facility staff had forgotten to distribute R1’s meals during several occasions. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 548-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5