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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 08/23/2024
Date Signed: 08/23/2024 11:52:00 AM

Substantiated


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
04/29/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240429145055
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: 68DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Julie Dion- AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to meet residents care needs
Staff did not treat resident with dignity or respect
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 allegations listed above. LPA met with Facility Administrator Julie Dion and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Facility failed to meet residents care needs. LPA conducted a file review on Resident #1 for the allegation: “facility failed to meet resident care needs”, during file review LPA obtained and reviewed video footages of Resident #1 LPA observed Resident #1 to be complaining of pain on two separate occasions to staff LPA observed that on both occasions staff disregarded Resident#1 complaint towards pain walked out of Resident#1 room without asking the resident if they were in need of medical help or assistance.

Second allegation, Staff did not treat resident with dignity or respect.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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 5
Control Number 56-AS-20240429145055
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: 08/23/2024
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
Regarding the allegation “staff did not treat resident with dignity of respect” LPA reviewed video footage of Resident #1 and observed that on multiple occasions Resident #1 was questioned by staff for yelling for help in addition, LPA also observed staff reprimanding Resident #1 for having staff going into residents’ room all night. Based on the evidence gathered during the investigation, the above allegations are Substantiated.

Substantiated: A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personal Rights 80072 (3); Personnel Requirements – General 87411 (a) from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.
An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights. to Facility Administrator Facility Administrator Julie Dion.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
04/29/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240429145055

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: 68DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Julie Dion- AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate food service to residents
Resident sustained a pressure injury due to neglect in care from staff
Staff did not return all of resident's medication at discharge
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 allegations listed above. LPA met with Facility Administrator Julie Dion and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff did not provide adequate food service to residents. LPA observed and inspected the quantity and quality of food on (2) separate facility visits. During initial visit LPA conducted a review of food service of the meals served. LPA collected a copy of the current menu, along with the alternative menu. LPA collected a copy of the internal food temperature logs and food handlers training certificates. LPA toured the facility and observed the meals that are being served reflected on what was on the menu for the week. LPA observed food to be of adequate quality. Meals appeared to be fresh and balanced. LPA conducted interviews with residents and residents indicated that the food that is served is okay and have no complaints. Residents also indicated that they have not gotten sick from the food that is served.

Second allegation, Resident sustained a pressure injury due to neglect in care from staff.
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: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20240429145055
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: 08/23/2024
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
Regarding the allegation “resident sustained a pressure injury due to neglect in care from staff”: LPA conducted interviews with staff regarding the allegation stated above, staff indicated that Resident#1 did not have a pressure injury however, staff did indicate that Resident #1 had redness and skin irritation, in which resident’s skin irritation was being treated with cream. Staff indicated to LPA that facility has no record on file for the pressure injury that is being indicated, because Resident #1 did not sustain a pressure injury. LPA conducted an interview with Resident #1 Primary Care Provider (NP), who confirmed to being the primary care provider from admission to resident#1 release. Nurse Practitioner stated that Resident #1 did not have a pressure injury but rather redness and skin irritation. Nurse Practitioner informed LPA that Resident#1 skin irritation was being treated with cream. NP informed LPA that Resident#1 skin irritation and skin break had eventually healed.

Third allegation, Staff did not return all of resident's medication at discharge. LPA conducted a file review of Resident#1 medication release LPA observed a list of medication pertaining to Resident #1 in addition, LPA observed a date along with a signature from Resident#1 authorized representative acknowledging the release/return of Resident#1 medication. Based on corroborating 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 Facility Administrator Julie Dion
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20240429145055
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
Personnel Requirements – General 87411 (a)...Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator has agreed to go over the Personnel Requirement-General regulation and provide training with all care staff. Administrator will ensure that training is signed and dated by all staff and provide proof to LPA Guerrero by POC date 9/20/2024.
8
9
10
11
12
13
14
Based on interviews and record review, facility did not meet Personnel Requirements for Resident #1, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Type B
09/20/2024
Section Cited
HSC
80072(3)
1
2
3
4
5
6
7
1) Personal Rights 80072 (3).... To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of punitive nature, including but not limited to: interference with the daily living function, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication, or aids to physical functioning.
1
2
3
4
5
6
7
Administrator has agreed to go over the Personnel Rights regulation and provide training with all care staff. Administrator will ensure that training is signed and dated by all staff and provide proof to LPA Guerrero by POC date 9/20/2024.
8
9
10
11
12
13
14
Based on interviews and record review, facility did not meet Personnel Rights for Resident #1, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
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: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5