361880893-7-15-2024-56-AS-KCLS-DA42VS-20241015174426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 07/15/2024
Date Signed: 07/15/2024 01:35:56 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/11/2024 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240711100038

FACILITY NAME:	PACIFICA SENIOR LIVING HILLSBOROUGH		FACILITY NUMBER:	361880893
ADMINISTRATOR:	JENNIFER HELDOORN		FACILITY TYPE:	740
ADDRESS:	11918 CENTRAL AVENUE		TELEPHONE:	(909) 548-2100
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY:	156	CENSUS: 127	DATE:	07/15/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Isabel Eriquez, Residence Service Director		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mishandled a resident's personal belonging
Staff did not provide comfortable accommodation for a resident
Staff did not properly maintain a resident's bathroom
Staff left a resident soiled for an extended period of time
Staff did not meet a resident's incontinence needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Residence Service Director Isabel Eriquez and explained the elements of the complaint. Investigation is based on documentation, observations, staff and resident interviews.

Regarding the allegation that staff mishandled a resident's personal belonging; The belonging in question is resident #1 (R1), in question, TV remote. Interview with staff revealed TV remote was misplaced by R1, but eventually found and returned to R1. R1 states that remote is in R1's procession. LPA observed TV remote in R1's room during time of investigation.

Regarding the allegation that staff did not provide comfortable accommodation for a resident; LPA interviewed R1 in assigned room during time of investigation and found the room to be clean and in order with a comfortable temperature. Interview with R1 stated that room is clean and properly maintained by facility staff.

***Continued on LIC 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

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 2

Control Number 56-AS-20240711100038

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLSBOROUGH	FACILITY NUMBER: 361880893
	VISIT DATE: 07/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation that staff did not properly maintain a resident's bathroom; Interview with staff #1 (S1) and S2 states that rooms cleaned according to facility cleaning maintenance procedures. Interview with R1 states bathroom and clean and maintained well. Observation by LPA Prieto, at time of visit, observed bathroom to be clean and free of odors.

Regarding the allegation that staff left a resident soiled for an extended period of time; S1 produced R1's service plan to reveal that R1 a two (2) person assistance, with additional time for changes if necessary. Hospice records reveal that R1's is changed during every visit. Interview with R1 revealed that changes are being conducted and has complaints about being left soiled for long periods of time.

Regarding the allegation that staff did not meet a resident's incontinence needs; Hospice records reveal that incontinence supplies are being provided by the Hospice Agency with Hospice staff documenting changes and continence needs being met during every visit. S1 confirmed incontinence supplies being provided by facility if necessary, but concluded that incontinence supplies are replenished but Hospice Agency after every visit.

Based on the information obtained there is not enough evidence that staff mishandled a resident's personal belonging, staff did not provide comfortable accommodation for a resident, staff did not properly maintain a resident's bathroom, staff left a resident soiled for an extended period of time and staff did not meet a resident's incontinence needs . Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Residence Service Director Enriquez and a copy was left with the facility.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2