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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880893
Report Date: 05/18/2022
Date Signed: 05/18/2022 01:40:55 PM


Document Has Been Signed on 05/18/2022 01:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA



FACILITY NAME:PACIFICA SENIOR LIVING HILLSBOROUGHFACILITY NUMBER:
361880893
ADMINISTRATOR:JENNIFER HELDOORNFACILITY TYPE:
740
ADDRESS:11918 CENTRAL AVENUETELEPHONE:
(909) 548-2100
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:156CENSUS: 111DATE:
05/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Jennifer Heldoorn, Executive DirectorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address violations observed during the investigation of complaint #18-AS-20200731095043.

On July 16, 2020, R1's primary physician authorized their home health agency to provide wound management due to the pressure ulcer identified on the resident's coccyx. On July 16, 2020, a home health representative responded to the facility to evaluate R1, however, the representative was denied entry into the facility. Interviews reported Staff One (S1) was the staff responsible for denying entry to the home health representative. S1 was interviewed and denied having done so. This posed an immediate threat to the health and safety of the resident in care. A citation will be issued.

Resident One (R1) was admitted to the hospital and confirmed COVID-19 positive. Several staff members indicate staff were not properly wearing masks throughout their shift. Resident Two (R2), began displaying COVID-19 symptoms on July 7, 2020, and was tested on July 10, 2020. The positive test results were returned on July 13, 2020 and R2 expired the same day. A few days later several residents were transported to the hospital. The facility did not conduct mass testing until July 29, 2020. This posed a potential threat to the health and safety of the residents in care. A citation will be issued.

An exit interview was conducted; this report was reviewed with Heldoorn and a copy provided, along with the LIC 811 and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/18/2022 01:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: PACIFICA SENIOR LIVING HILLSBOROUGH
FACILITY NUMBER: 361880893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited

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Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement was not met, as evidenced by: Based on interviews the Licensee did not
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ensure R1 maintained the right to receive medical care. On 07/16/20, a home health representative responded to the facility to evaluate R1, however, the representative was denied entry into the facility.
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Type B
05/31/2022
Section Cited

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Personal Rights of Residents in All Facilities: Residents in all RCFEs shall have all of the following personal rights: To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement was not met, as evidenced by: Based on interviews, the licensee did not ensure residents
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were accorded safe, healthful, & comfortable accomodations. Staff members indicate staff were not properly wearing masks throughout their shift. The facility did not conduct mass testing until 07/29/20. This posed a potential threat to the health and safety of the residents in care.
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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: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
LIC809 (FAS) - (06/04)
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