361880893-5-16-2024-18-AS-JDHS-D5VKJX-20240603075722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:28:42 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2020 and conducted by Evaluator Yolanda Delgado

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20201012132303

FACILITY NAME:	PACIFICA SENIOR LIVING HILLSBOROUGH		FACILITY NUMBER:	361880893
ADMINISTRATOR:	TAYLOR, MANDY		FACILITY TYPE:	740
ADDRESS:	11918 CENTRAL AVENUE		TELEPHONE:	(909) 548-2100
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY:	156	CENSUS: 127	DATE:	05/16/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Jennifer Heldoorn, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident's room is not kept sanitary.
Resident's room is malodorous.
Resident has spoiled foods in their room.
Resident's room has mold.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Jennifer Heldoorn and explained the purpose of the visit. During the course of the investigation, records were reviewed, and interviews were conducted with facility staff members and residents.

On October 12, 2020, Community Care Licensing received a complaint alleging that resident’s room is not kept sanitary, resident’s room is malodorous, resident has spoiled foods in their room, and resident’s room has mold.

Regarding the allegation that “Resident’s room is not kept sanitary”, facility records revealed that facility had sufficient staff on shift to clean schedule rooms as assigned with house cleaning checklist. R1 was unable to be interviewed as R1 no longer lives at the facility and is unable to be interviewed. Interviews with staff denied that R1’s room was not kept sanitary by facility staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20201012132303

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH	FACILITY NUMBER: 361880893
	VISIT DATE: 05/16/2024

NARRATIVE

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(Continued from Page 1)

Regarding allegation that “Resident’s room is malodorous”, facility records revealed that that facility had sufficient staff on shift to clean schedule rooms as assigned with house cleaning checklist. R1 was unable to be interviewed as R1 no longer lives at the facility and is unable to be interviewed. Interviews with staff denied that R1’s room was malodorous by facility staff.

Regarding allegation “Resident has spoiled foods in their room”. Facility records revealed that the facility staff would be in/out of resident’s room to deliver food trays, clean room, and empty trash daily. R1 was unable to be interviewed as R1 no longer lives at the facility and is unable to be interviewed. Interviews with staff denied that R1’s room had spoiled food left in R1’s room.

Regarding the allegation “Resident’s room has mold”. External records revealed that what appears to be mold was not mold. R1 was unable to be interviewed as R1 no longer lives at the facility and is unable to be interviewed. Interviews with staff denied that R1’s room had mold.

Therefore, the allegations of resident’s room is not kept sanitary, resident’s room is malodorous, resident has spoiled foods in their room, and resident’s room has mold is Unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted with Jennifer Heldoorn and a copy of this report along with LIC811- Confidential Names list was provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC9099 (FAS) - (06/04)

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