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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425024
Report Date: 06/27/2023
Date Signed: 06/27/2023 10:17:27 AM


Document Has Been Signed on 06/27/2023 10:17 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



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: 72DATE:
06/27/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Director Julie DionTIME COMPLETED:
10:20 AM
NARRATIVE
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On 06/27/2023 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director (ED) Julie Dion at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office for a Case Management Deficiency. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

During the facility visit last 06/02/2023, LPA Brown toured the facility, observed residents in care in the dining area during the visit. LPA Brown requested a copy of Resident Roster and LIC500 Personnel Report from Executive Director Julie Dion. During the process of the investigation, LPA Brown observed last 06/24/2023 that Staff #7 (S7) was working at the facility since 03/14/2021 without criminal background clearance exemption as S7 criminal exemption was denied. On 06/26/2023, LPA Brown contacted ED Dion via telephone and informed ED Dion that S7 must act immediately to remove S7 at the facility as S7 does not have criminal background clearance due to S7's Criminal Exemption being denied. LPA Brown explained to ED Dion that deficiency will be issued as this pose immediate health, safety and personal rights risk to residents in care.



A civil penalty of $500.00 was assessed for Staff #7 working at the facility without criminal background clearance exemption and will continue to be assessed of $100.00 per day until corrected during the Office visit.

Also, during the investigation, LPA Brown discovered that the facility failed to report Resident #9 death at the facility to Community Care Licensing Division (CCLD). LPA Brown informed ED Dion that Technical Violation will be issued to the facility for this issue.

An exit interview was conducted where this report, LIC809, along with LIC809D, LIC421BG, LIC9102 and Appeal Rights were discussed and provided to Executive Director Julie Dion.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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 06/27/2023 10:17 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: PACIFICA SENIOR LIVING CHINO HILLS
FACILITY NUMBER: 366425024

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2023
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (1) Obtain a California clearance or a criminal record exemption... This requirement is not met as evidenced by:
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Licensee stated to immediately remove Staff #7 at the facility and not to allow S7 to work without criminal background exemption.
Licensee stated to submit Signed Statement of Understanding on CCR 87355(e)(1) to LPA Brown by POC due date.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Staff #7 to work at the facility without criminal backround exemption since 03/14/2021 whick pose immediate health, safety and personal rights risk to 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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
LIC809 (FAS) - (06/04)
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