<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 02/09/2024
Date Signed: 02/09/2024 01:18:44 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
11/09/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231109090240
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
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lizeth GomezTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure that residents were administered their medications as prescribed.
Staff member does not have required training to provide care to residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Office Manager Lizeth Gomez and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff did not ensure that residents were administered their medications as prescribed. During interviews and review of records LPA observed that medications was administered to all resdients however, due to staffing coflict residents medication was administered late based on Med Variance report.

Second allegation, Staff member does not have required training to provide care to residents. During interviews and review of records LPA observed training certificates for all Med-Techs along with staffing support to be on file. Based on documentation and trainings facility staff have the qualifications to provide care to residents. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20231109090240
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: 02/09/2024
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
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 (LIC 9099) was discussed, and a copy was provided to Office Manager Lizeth Gomez at the end of the visit.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2