361880893-6-23-2021-18-AS-RLAY-C4NTLZ-20210706145023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:06:54 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
06/22/2021 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210622153222

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: 116	DATE:	06/23/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Mandy Taylor, Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility does not have hot water.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived to the facility to initiate a complaint investigation into the allegation listed above. LPA met with Executive Director (ED) Mandy Taylor and discussed the purpose of the visit and the elements of the allegation. During today's visit, LPA toured the facility, interviewed seven (7) residents, three (3) staff, and obtained copies of pertinent records. Regarding the allegation "facility do not have hot water", it was alleged that the entire facility has not had hot water since June 16, 2021. Interviews with ED and Business Office Manager Claudia Ruiz revealed the facility's boiler was experiencing difficulties with the pilot light resulting in the pilot light not staying lit. Per documents provided by ED, the facility took measures to diagnose the problem immediately upon it's discovery on June 3, 2021 by contacting a repair company to come to the facility to determine the problem. The documentation further revealed an order for an entire boiler system replacement has been made and the facility is awaiting an install date from the contractor. At 2:20 PM, LPA began measuring the hot water temperatures in rooms #210, #240, #302, #319, #108, and #137. The hot water in room #210 measured 75.3 degrees Fahrenheit, in room (CONTINUED ON LIC 9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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-20210622153222

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: 06/23/2021

NARRATIVE

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(CONTINUED FROM LIC 9099)
#240 it measured 74.3 degrees Fahrenheit, in room #302 it measured 76.0 degrees Fahrenheit, in room #319 it measured #75.7 degrees Fahrenheit, in room #108 it measured 76.5 degrees Fahrenheit, and in room #137 it measured 75.4 degrees Fahrenheit. LPA also measured the hot water in the kitchen at the dishwashing station to be 129 degrees Fahrenheit. One (1) of seven (7) residents interviewed reported having no hot water at all. Six (6) of seven (7) residents interviewed reported the facility's hot water is operable but only at specific times each day.

This agency has investigated the complaint alleging "Facility does not have hot water". We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

An exit interview was conducted and a copy of this report was provided.

*This is an amended report

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC9099 (FAS) - (06/04)

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