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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 03/21/2022
Date Signed: 03/21/2022 04:33:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 18-AS-20220112115948
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: 84DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Julie Olmedo - Administrator TIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not keeping facility free from pests.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Bernadette Allen made an unannounced visit to the facility for the purpose of initiating and delivering findings on a complaint. LPA met with Executive Director Julie Olmedo.

LPA toured the facility, reviewed facility documentation, and conducted interviews with residents and staff. The allegation indicates “Staff not keeping facility free from pests” LPA was informed by administrator Julie Olmedo that the facility is contracted with Dewy pest control that inspects once a month. LPA observed the pest control invoices dated from October 2021-March 2022. LPA observed the facility did repair a hole in the wall to prevent pest from entering. The general consensus was that the pest control service has been effective and there are currently no problems with PEST.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED
at this time.
No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the Executive Director.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 18-AS-20220112115948

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: DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Julie Olmedo - Administrator TIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Multiple residents sustained food poisoning.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The investigation consisted of interviews with (6) six staff and (5) five residents. All residents and staff members have confirmed that there hasn’t been any complaints or situations regarding food poisoning.

Based on these interviews and investigated we have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

No deficiencies were cited during this visit.

An exit interview was conducted where this report was discussed with administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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 2