366425024-5-15-2024-56-AS-EMAN-D5QNGR-20240529102732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 05/15/2024
Date Signed: 05/15/2024 11:07:17 AM

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
02/06/2024 and conducted by Evaluator Paola Guerrero

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20240206105318

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: 63	DATE:	05/15/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Julie Dion		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Facility roof is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Administrator Julie Dion and explained the purpose of the visit. The investigation consisted of Observation, interviews, and review of records.

First allegation, Facility roof is in disrepair. On 2/9/2024 LPA conducted a walkthrough of the facility dining room area and observed that a flyer indicating “Dining room is under repair” was posted on the entrance of dining the dining room door. LPA observed that the dining room was enclosed and observed building material to be present. Facility administrator informed LPA that the dining room area had a roof leak and that they are in the process of repair. Facility Administrator informed LPA that residents along with family members were made aware of the repairs and informed all residents that meal accommodations will be delivered to each resident’s rooms until the dining room leak repair is complete. LPA observed invoices along with city inspections invoices, indicating roofing repairs.

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: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20240206105318

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: 05/15/2024

NARRATIVE

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LPA conducted interviews with Residents, and all stated that they were informed of the repairs and for the mean time all meals are being delivered to their rooms while the dining room area is repaired. On 5/15/2024 LPA conducted a second walkthrough of the facility dining room area and observed that the roof was repaired, and no new damage was observed. LPA observed that the dining area was open and accessible for all residents. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegation is 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 Facility Administrator Julie Dion.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

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