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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425024
Report Date: 02/09/2024
Date Signed: 02/09/2024 01:25:02 PM


Document Has Been Signed on 02/09/2024 01:25 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 HILLSFACILITY NUMBER:
366425024
ADMINISTRATOR:JULIE OLMEDOFACILITY TYPE:
740
ADDRESS:6500 BUTTERFIELD RANCH RDTELEPHONE:
(909) 606-2553
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY:94CENSUS: 91DATE:
02/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lizeth GomezTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced case management visit during complaint control number 56-AS-20231109090240. LPA met with Office Manager Lizeth Gomez and explained the reason for the visit.

During initial visit facility failed to provide special incident report (SIR), reporting the administration of medication to be given late to residents due to staffing conflict.

Based on this matter, one (1) one deficiency was cited per Title 22, Division 6, of the California Code of Regulation.

An exit interview was conducted where this report (LIC 809) was discussed and and copy was provided to Office Manager Lizeth Gomez.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
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 02/09/2024 01:25 PM - 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2024
Section Cited
CCR
87211(a)(1)

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Reporting Requirements.. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met a evidence by:
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Administrator has agreed to read over the regulation pertaining to Reporting Requirements and provide training to all staff. The completion of training signed and dated by all staff will be emailed to LPA Guerrero on POC date of 3/1/2023.
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Based on record review, the licensee did no ensure to follow the proper procedures to report CCL office that medication was administered late to all residents due to staffing conflicts.
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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: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2