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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:28:16 PM

Unfounded


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 HILLSBOROUGHFACILITY NUMBER:
361880893
ADMINISTRATOR:TAYLOR, MANDYFACILITY TYPE:
740
ADDRESS:11918 CENTRAL AVENUETELEPHONE:
(909) 548-2100
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:156CENSUS: 127DATE:
05/16/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jennifer Heldoorn, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not notify responsible party of rent increase.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegation 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 facility staff did not notify responsible party of rent increase.
It was alleged that facility staff did not notify responsible party of rent increase. Interviews with facility staff and Resident’s responsible party revealed that Resident 1’s responsible party confirmed that the rent increase had not been automatically taken out of account and R1 was moved out of the facility before the rent increase was going into effect. LPA reviewed facility records dated July 25, 2020, where R1’s responsible party was mailed a letter with the effective date of the increase.
This agency has investigated the complaint alleging "facility staff did not notify responsible party of rent increase". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to facility representative.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (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)
Page: 1 of 1