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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 02/06/2025
Date Signed: 02/06/2025 01:42:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
11/18/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241118091753
FACILITY NAME:PACIFICA SENIOR LIVING CHINO HILLSFACILITY NUMBER:
366425024
ADMINISTRATOR:JULIE OLMEDOFACILITY TYPE:
740
ADDRESS:6500 BUTTERFIELD RANCH RDTELEPHONE:
(909) 606-2553
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY:94CENSUS: 68DATE:
02/06/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Julie Olmedo- AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not properly maintain the facility
Staff do not properly report incidents involving a resident
Staff do not meet the needs of a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Julie Dion and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Staff did not properly maintain the facility. Regarding the allegation, LPA conducted a facility walkthrough accompanied by facility administrator. During the walkthrough LPA observed facility to be clean, in good repair, and operating in safe conditions for residents in care. LPA conducted an inspection inside Resident #1 room and observed room to be clean, well-organized, and free from bodily fluids.

Second allegation: Staff do not properly report incidents involving a resident. Regarding the allegation “Staff do not properly report incidents involving a resident” LPA requested records pertaining to Resident #1 regarding R#1 incident reports. During record review LPA discovered that on 11/6/2024 R#1 sustained a fall which resulted in R#1 loosing front tooth.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
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-20241118091753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: PACIFICA SENIOR LIVING CHINO HILLS
FACILITY NUMBER: 366425024
VISIT DATE: 02/06/2025
NARRATIVE
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In addition, LPA discovered that facility contacted local paramedics to evaluate R#1, incident report also reported that POA spoke to paramedics and requested for R#1 not to be taken to hospital. Since the last incident LPA observed that the last incident involving R#1 was reported on 11/11/2024, incident was also reported to R#1 POA.

Third allegation: Staff do not meet the needs of a resident. Regarding the allegation “Staff do not meet the needs of a resident” LPA requested documentation pertaining to Resident #1 care needs. During record review LPA discovered that facility conducted an assessment to determine the level of care for R#1. Facility implemented Falls intervention, by conducting more status checks for R#1 in addition, facility implemented escorts by ambulation with wheelchair for R#1. LPA conducted an interview with Resident #1 who informed LPA that resident likes the facility and has no concerns regarding care staff. Resident#1 informed LPA about feeling safe at the facility. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

Unsubstantiated: meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Julie Dion at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC9099 (FAS) - (06/04)
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