366425024-6-27-2023-56-AS-EMAN-CTASNR-20230630140156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 06/27/2023
Date Signed: 06/27/2023 10:14:00 AM

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
07/25/2022 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220725101431

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: 72	DATE:	06/27/2023
		ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Director Julie Dion		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Residents call pendants are in disrepair.
Staff are mismanaging residents medication.
Facility did not have proper emergency procedures during blackout.
Staff are not meeting residents needs.

INVESTIGATION FINDINGS:

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On 06/27/2023 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director Julie Dion at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of observation and interviews with relevant parties. The first allegation indicates that Residents call pendants are in disrepair. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs and residents indicated that the pendants are in good condition and in working order and not in disrepair. During the visit last 06/02/2023, LPA Brown requested residents to press their call pendant to check if the call pendant is working order and also check the staff response time and LPA Brown determined that the residents call pendants are working and not in disrepair and care staff response time are between five (5) minutes to ten (10) minutes. *** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20220725101431

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: 06/27/2023

NARRATIVE

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The second allegation indicates Staff are mismanaging residents’ medication. Interviews with residents indicated that staffs are not mismanaging their medications and no incidents happened at the facility that staffs mismanaged their medications. Staffs’ interviews indicated that medical technician (MedTech) staffs are dispensing medications to residents per doctor’s order, per schedule and appropriately recording it on each resident’s medication administration record (MAR). During the visit last 06/02/2023, LPA Brown checked residents’ medications and MAR and observed that MedTech staffs are appropriately dispensing residents’ medications per doctor’s order.

The third allegation indicates Facility did not have proper emergency procedures during blackout. Interviews with residents indicated that the facility had a proper emergency procedure in place during a blackout and there's no incident that happened at the facility that there's a blackout and no emergency procedure was in place. Staff interviews revealed that there's a proper emergency procedure in place at the facility and though staffs reported to LPA Brown that though the facility doesn’t have a back-up generator, they are renting a generator at a nearby depot store if needed. Staffs interviews also indicated that they have eight (8) Emergency lights that are mostly on hallways and exits and there's no incident that happened at the facility that there's a blackout and the facility does not have a proper emergency procedure.

The fourth allegation indicates Staff are not meeting resident’s needs. Interviews with residents indicated that all staffs at the facility are providing care and supervision to all the residents at the facility and there's no incident happened that a staff did not meet a residents' needs. Staffs’ interviews indicated that they are meeting the needs of their residents because they are all providing care and supervision to all the residents at the facility. Staffs’ interviews revealed that staffs at the facility are treating their residents as family, and they love what they do. During the visit last 06/02/2023, LPA Brown observed staffs at the facility assisting residents in their room, at the hallway, at the dining area, in the activity room, at the reception area.

Based on observations, interviews, and records review, the allegation Residents call pendants are in disrepair (Allegation #1), Staff are mismanaging residents’ medication (Allegation #2), Facility did not have proper emergency procedures during blackout (Allegation #3), Staff are not meeting resident’s needs (Allegation #4) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. *** Continuation in LIC9099C ***

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20220725101431

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: 06/27/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	An exit interview was conducted, where this report (LIC9099) was discussed and provided to Executive Director Julie Dion.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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