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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425024
Report Date: 06/02/2023
Date Signed: 06/02/2023 03:18:06 PM


Document Has Been Signed on 06/02/2023 03:18 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 71DATE:
06/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Business Office Manager Liseth GomezTIME COMPLETED:
03:20 PM
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
On 06/02/2023 at 10:45 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility for a Case Management Deficiency visit. LPA Brown identified herself and discussed the purpose of the visit with Business Office Manager Liseth Gomez

During the facility visit today, LPA Brown toured the facility, observed residents in care in the dining area during the visit. LPA Brown requested a copy of Resident Roster and LIC500 Personnel Report from Executive Director Julie Dion. LPA Brown interviewed Staff # 4 (S4), reviewed staff working at the facility in reference to the provided LIC500 Personnel Report and Guardian Background System and interviewed Staff # 2 (S2) and both S4 and S2 confirmed that S4 had been working at the facility for about four years now with criminal background clearance but the facility failed to transfer S4's criminal background clearance to the facility. LPA Brown explained to Business Office Manager Liseth Gomez that deficiency will be issued as this pose potential health, safety and personal rights risks to residents in care.



A civil penalty of $500.00 was assessed for Staff #4 working at the facility with criminal background clearance but the facility failed to transfer S4's criminal background clearance to the facility for S4 to be associated to the facility and will continue to be assessed of $100.00 per day until corrected during the visit.

An exit interview was conducted where this report, LIC809, along with LIC809D, LIC421BG and Appeal Rights were discussed and provided to Business Office Manager Liseth Gomez
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/02/2023 03:18 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
06/09/2023
Section Cited
CCR
87355(e)(2)

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... (2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Licensee transferred Staff #4 criminal background clearance to the facility during the visit.
Licensee stated to submit signed Statement of Understanding on CCR 87355(e)(2) to LPA Brown by POC due date.
8
9
10
11
12
13
14
Based on observation, interview and records review, the Licensee did not comply with the section cited above by not transferring the criminal background clearance of Staff #4 to the facility who had been working at the facility for four years which pose potential health, safety and personal rights risks to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2