366425024-5-22-2023-56-AS-MMAE-CS3SWX-20230522141505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366425024
Report Date: 05/22/2023
Date Signed: 05/22/2023 02:15:16 PM

Document Has Been Signed on 05/22/2023 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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:	05/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Julie Dion - Executive Director		TIME COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Julie Dion, Executive Director and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). Licensed capacity is (94) with a hospice waiver for (15). The current census is (68). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient furniture and activity space for clients in care. The facility has sufficient lighting and is maintained at a comfortable temperature 75 degrees F.

LPA inspected the kitchen. Facility has sufficient non-perishable and perishable food for the number of clients in care. Menus are posted in various areas of the facility. Facility food is stored in a safe and healthful manner. Sharps are stored and kept locked and inaccessible to clients in care.

LPA inspected six (6) client bedrooms. Bedrooms are equipped with required furniture such as: mattresses, nightstands and storage space. Bedrooms have sufficient linen and lighting.

LPA inspected six (6) client bathrooms. Bathrooms were equipped with handrails and operating in safe and sanitary conditions. The hot water temperature tested within regulation at 108 degrees F.

LPA observed the facility is equipped with operating carbon monoxide alarms and fully charged fire extinguishers. Fireplace adequately screened and operating telephone service. Posters such as personal rights, Complaint reporting, facility sketch, the disaster plan were posted in a common area. Emergency drill conducted on 4/07/2023. Cleaning supplies, toxins, items were kept locked and inaccessible to clients in care.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/22/2023

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The facility is equipped with two (2) centrally store medication rooms. Medications are kept in safe and locked cabinets inaccessible to clients in care. LPA reviewed six (6) client medications and centrally stored medication logs. All medication were administered as prescribed and labeled as required by Sate and Federal laws.

All staff files reviewed had criminal record clearance, training, and health screenings. All client records reviewed has admissions agreements, physician's report, and personal rights statements. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, California Code of Regulations.

An exit interview was conducted, where this report (LIC809) was discussed and a copy of report with appeal rights was provided to the Executive Director at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

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