361880893-2-19-2021-18-AS-NBRN-BZ7MCB-20210317092913

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 02/19/2021
Date Signed: 02/19/2021 09:15:24 PM

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2020 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200728152434

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: 101	DATE:	02/19/2021
		UNANNOUNCED	TIME BEGAN:	03:57 PM
MET WITH:	Mandy Taylor, Executive Director		TIME COMPLETED:	04:18 PM

ALLEGATION(S):

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Resident was not provided with comfortable accommodations

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone to deliver the findings of the investigation via telephone due to COVID-19. LPA identified herself and discussed the purpose of the call with Executive Director (ED), Mandy Taylor.

Regarding the allegation, "Resident was not provided with comfortable accommodations," it was alleged the temperature in Resident One's (R1's) bedroom was observed, on July 26, 2020, to be hot and registered at eighty-five (85) degrees Fahrenheit. The LPA initiated the investigation on August 06, 2020. Interviews were conducted with both staff and residents. According to staff, there are individual heating/cooling units in each resident bedroom. Executive Director (ED), Mandy Taylor, reported the thermostats are secured in locked boxes and cannot be manipulated by residents. Resident interviews reported staff are accommodating when asked to change the temperature in their bedrooms to a more comfortable degree. Fifteen (15) of the nineteen (19) interviews conducted reported temperatures are maintained at either approximately seventy (70) degrees

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

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

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2020 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200728152434

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: 101	DATE:	02/19/2021
		UNANNOUNCED	TIME BEGAN:	03:57 PM
MET WITH:	Mandy Taylor, Executive Director		TIME COMPLETED:	04:18 PM

ALLEGATION(S):

1
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9

Staff failed to address pest infestation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, contacted the facility via telephone to deliver the findings of the complaint investigation via telephone due to COVID-19. The LPA identified herself and discussed the purpose of the call with Executive Director (ED), Mandy Taylor.

Pertaining to the allegation, "Staff failed to address pest infestation," it was alleged R1 was found, on July 26, 2020, with ants crawling over their face and body. It was also alleged the resident had ants in their mouth and eyes for two (2) days. Staff interviews and records review revealed R1 was found with ants crawling over their face and body on July 25, 2020, the morning of July 26, 2020 and the evening of July 26, 2020. Staff interviews reported it is the facility's protocol to clean the site, notify management, and have maintenance staff treat the area temporarily until a fumigation company is able to make contact. It was also reported staff, after each observation, cleaned up the resident, changed their sheets, and notified management. A work order revealed treatment of R1's bedroom was later conducted on August 03, 2020 by a fumigation company. Evidence was obtained to show care staff did notify maintenance department staff about the infestation on July 26, 2020;

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

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-20200728152434

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
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH	FACILITY NUMBER: 361880893
	VISIT DATE: 02/19/2021

NARRATIVE

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however, the guidance issued by maintenance to care staff was not followed. This posed an immediate health and safety risk to R1. The allegation is deemed SUBSTANTIATED at this time. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted with ED Taylor via telephone and a copy of this report was provided to via email

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20200728152434

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
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH	FACILITY NUMBER: 361880893
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/01/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation: The facility shall be clean, safe, sanitary & in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety and well-being of residents, employees & visitors. This requirement was not met as evidenced by: Based on interviews & records	1 2 3 4 5 6 7	The Executive Director stated in-service training will be provided to all staff and the schedule will be updated for house keep staff to ensure coverage is available.
	8 9 10 11 12 13 14	review the Licensee did not ensure procedures were followed by staff regarding pest infestation. Evidence was obtained to show care staff did notify maintenance staff about the infestation on 7/26/20; however, the guidance issued was not followed. R1 was found with ants crawling over their face & body.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 18-AS-20200728152434

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
RIVERSIDE, CA 92507

FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH	FACILITY NUMBER: 361880893
	VISIT DATE: 02/19/2021

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	Fahrenheit or at another comfortable temperature. R1 was not available to be reached for an interview. The allegation is deemed UNSUBSTANTIATED at this time. An exit interview was conducted with ED Taylor via telephone and a copy of this report was provided via email and receipt of report confirmed.

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5