361880893-11-9-2021-18-AS-NBRN-C9D2FG-20211203162131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 11/09/2021
Date Signed: 11/09/2021 11:25:45 AM

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
11/05/2021 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211105141454

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: 105	DATE:	11/09/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jennifer Heldoom, Executive Director		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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1)Resident sustained fall while in care.
2)Facility staff was not sufficient to meet residents needs.

INVESTIGATION FINDINGS:

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On 11/9/21 Licensing Program Analyst(LPA) Shaunte Henry conducted an unannounced visit for the purpose of investigating the above allegations. The LPA met with Executive Director (ED) Jennifer Heldoorn, explained the nature of the visit and was granted entry.

The investigation, which consisted of interviews and file review revealed the following in regard to the above allegations: Interviews with the ED and Memory Care Director, Brittany Whitlock, revealed that Resident 1 (R1) was admitted to the facility on 10/16/21 to the transitional memory care unit. R1 would be moved to the Legacies memory care unit on the 2nd floor after R1's room floor was completed. The Legacies unit cares for residents that require more care than transitional residents.
***Continued on 9099C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

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-20211105141454

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: 11/09/2021

NARRATIVE

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***Continued from 9099***

R1's pre-appraisal indicates 2 hour checks, however the facility conducted 1 hour checks due to R1 being sedated with Ativan prior to being admitted on 10/16/21. The facility also wanted to ensure a better transition for R1. R1 sustained two falls on 10/17/21. The second fall resulted in R1 hitting their head, therefore R1 was taken to the hospital for evaluation. The facility decided that it was in the best interest of R1 to be taken to the hospital and not to wait until hospice arrived. R1's responsible party picked R1 up from the hospital and took R1 back to Pacifica Senior Living Hillsborough. The responsible party was aware that R1's Legacies memory care room would not be available until 10/18/21 or 10/19/21. R1 went home with the responsible party on 10/17/21 and did not return. The responsible party provided a 30-day notice on 10/19/21. R1 passed away at home with family on 10/20/21. An interview with the memory care director, revealed staffing was not insufficient in the transitional memory care unit on 10/17/21. From 10:00PM- 6:00AM there was 1 caregiver to 22 residents. From 6:00AM- 2:00PM there were 3 caregivers and 1 med tech to 22 residents. R1 should have been housed in the Legacies memory care unit where the staffing to resident ration is 2 caregivers to 10 residents in the day and 1 caregiver to 10 residents at night. Both allegations have been found to be substantiated.

Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, 9099D, LIC 811 and appeal rights were provided to the ED

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20211105141454

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: 11/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/09/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights of Residents in all Facilities:To be accorded safe, healthful & comfortable accommodations, furnishings and equipment.This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licesnee shall read this regulation in it's entirety and submit a statement of understanding by the POC due date.
	8 9 10 11 12 13 14	Based on interview and file review. R1 fell twice on 10/17/21. R1 passed on 10/20/21. R1 was waiting on a room in the Legacies MC unit. This is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 11/09/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements: personnel shall be sufficient in numbers and competent to provide the services necessary to meet the residents needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licesnee shall read this regulation in it's entirety and submit a statement of understanding by the POC due date.
	8 9 10 11 12 13 14	Based on interviews and file review, R1 was temporarily placed in the Transitional unit.R1 fell twice on 10/17/21. This is an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

LIC9099 (FAS) - (06/04)

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