366425024-1-25-2023-56-AS-KCLS-CNX25J-20230210160537

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 01/25/2023
Date Signed: 01/25/2023 01:07:14 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
01/24/2023 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230124083924

FACILITY NAME:	PACIFICA SENIOR LIVING CHINO HILLS		FACILITY NUMBER:	366425024
ADMINISTRATOR:	JULIE OLMEDO		FACILITY TYPE:	740
ADDRESS:	6500 BUTTERFIELD RANCH RD		TELEPHONE:	(909) 606-2553
CITY:	CHINO HILLS	STATE: CA	ZIP CODE:	91709
CAPACITY:	94	CENSUS: 74	DATE:	01/25/2023
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Julie Dion, Executive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Questionable death
Staff do not answer resident calls
Staff speaks inappropriately to residents in care
Resident rooms are not kept free of vermin
Residents are not provided proper laundry services
Facility is in disrepair
Residents are not provided proper food service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above listed allegations. LPA Prieto met with Director Julie Dion toured facility and interviewed residents (R1, R2, R3. R4, R5, R6, R7,) in their rooms. Rooms are clean and free of insects and vermin. Consensus was that staff treat them well, cleaning and laundry staff address their needs without complaints and staff are attentive when called upon. Observation of dining area was clean and neat. Interview with Kitchen Director (S1) states that meals are served on time with more then sufficient portions. Copy of sample meal menu shows meals of quality and are balanced. It was observed, during tour, that a water leak is being addressed and interview with Maintenance Director (S2) reveals leak has been contained, with further maintenance for permanent fix or even possible repair. Interview Laundry Manager (S3), in facility laundry room, reveals laundry is being completed in a timely manner. LPA Prieto observed facility concierge answering incoming phone calls without delay during LPA visit.

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: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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 56-AS-20230124083924

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 CHINO HILLS	FACILITY NUMBER: 366425024
	VISIT DATE: 01/25/2023

NARRATIVE

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Recent resident's (R8) passing was documented by staff and Resident Service Director (S4) and provided LPA with documentation of the moment of that resident's passing as well as follow up and appears to follow the proper procedures.

Based on the information obtained there is not enough evidence that the aforementioned allegation were violated. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC9099 (FAS) - (06/04)

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