366425024-2-9-2024-18-AS-EMAN-D2V2MD-20240227163057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 02/09/2024
Date Signed: 02/09/2024 01:31:37 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
12/28/2021 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211228082003

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: 91	DATE:	02/09/2024
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Lizeth Gomez		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility not adequately cleaned.
Staff do not provide adequate food services 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, Facility not adequately cleaned. During interviews and review of records LPA observed that housekeeping is completed on daily basis. LPA conducted a walkthrough of the facility and observed facility to be clean and clear of obstructions.

Second allegation, Staff do not provide adequate food services to residents. During interviews, record review and observations, LPA conducted a walkthrough of facility kitchen an observed kitchen to be clean and observed all kitchen appliances to be clean and sanitized. LPA inspected non-perishable and perishable food supply and observed food to be in good standing based on expiration dates. LPA conducted interviews with kitchen staff, and all stated that any left-over food gets tossed after two hours no food gets re-stored.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (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 18-AS-20211228082003

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

LPA collected facility menu and observed that facility offers alternative food options for residents. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (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