366425024-3-3-2023-56-AS-EMAN-CR2SEY-20230419134932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 03/03/2023
Date Signed: 03/03/2023 01:04:44 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
03/02/2023 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230302144551

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: 68	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Liseth Gomez		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Facility staff is preparing food for residents while infected with Staph Infection

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to initiate and deliver the findings for the above complaint allegation. LPA met with Business Office Manager Liseth Gomez who was informed of the purpose of the visit and the allegation listed above. The investigation consisted of direct observations, and interviews with staff regarding the allegation.

Allegation: Facility staff is preparing food for residents while infected with Staph Infection

Licensing Program Analyst (LPA) Paola Guerrero interviewed seven (7) staff members. While conducting the investigation staff member S2, S3, S4, S5, and S6, stated that they never witnessed S1 handle or prepare food with open cuts or wounds. S4, S5, and S6, all stated that S1, always utilized gloves when working in the kitchen and handling food. S5, stated cannot recall a time or day that S1 did not wear gloves when handling food.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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-20230302144551

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: 03/03/2023

NARRATIVE

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S2 and S3 both stated that no reports were made by S1 noting any concerns regarding cuts or open wounds. S4, S5, S6, and S7 all stated in the event that they were to witness any staff handling food without gloves or open wounds that the matter would immediately be voiced out to the kitchen manager. S4, S5, S6, and S7, all stated that they have not witnessed any kitchen staff member of handling food without gloves, cuts, or open wounds. Based on the observation and interviews LPA has determined that the above allegation is 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, LIC9099 was discussed and provided to Business Office Manager Liseth Gomez

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC9099 (FAS) - (06/04)

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