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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 07/01/2022
Date Signed: 07/01/2022 12:03:03 PM

Substantiated


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
06/29/2022 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220629090628
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: 66DATE:
07/01/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Julie Olmedo, Executive DirectorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility kitchen is not clean and sanitary
Facility appliances are in disrepair
INVESTIGATION FINDINGS:
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This unannounced visit by Amy Goldenberg, Licensing Program Analyst (LPA), to initiate the 10 day visit to investigate the above-mentioned complaint allegations. LPA mer with Executive Director Julie Olmedo and discussed the elements of the alleged violations.

Investigation included interviews with staff, tour of the kitchen for cleanliness and assessment of the appliance condition. Photographs of the kitchen condition were taken. LPA was informed that the kitchen had been cleaned the night before, and that cleaning included mopping and sweeping the floors and wiping counters. LPA observed the following in the kitchen: The kitchen floors are sticky with grease and have food particles and rodent droppings present. Frequently touched kitchen walls, doors, and fixtures are visibly dirty. The inside of refrigerators are dirty. Dry good food storage floors and trays are dirty and have rodent droppings present. Walk in refrigerator floors are dirty.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
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 4
Control Number 56-AS-20220629090628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 07/01/2022
NARRATIVE
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 Freezer floors are dirty. There is food frozen to the walls and floor of the freezer. LPA observed that the ceiling had damage and is informed that there was water damage to the area. There is the presence of a black substance on the ceiling above the food prep area. Facility appliances in disrepair include an oven called a Salamander Oven. The oven is in disrepair, rusty and covered in grease. It is partially taken apart and has observable rodent droppings inside it. There is a broken steam cabinet that requires cleaning. There is a broken refrigerator being used as a dry good storage.

Based on LPA observations it is confirmed that the facility kitchen is not clean and sanitary
and that there are appliances in disrepair and the condition poses a potential risk to the health of safety of those preparing and those receiving foods prepared in that area.

We have substantiated the complaint allegations as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20220629090628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2022
Section Cited
CCR
87555(b)(29)
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General Food Service
Requirements: All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair...The facility has not met this requirement as evidenced by LPA
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The licensee to repair and deep clean or remove all kitchen appliances in disrepair by POC due date 7/5/2022.
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observation of broken/dirty Salamander oven, steam cabinet and refrigerator. This is a health and safety potential for those working and receiving foods prepared in this environment.
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Type A
07/05/2022
Section Cited
CCR
87555(b)(27)
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All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. The facility has not met this requirement as evidenced by LPA observation
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The licensee to provide a deep cleaning to all kitchen floors, walls, freezer walls and floors, refrigerators, tables, steam tables, cabinetry, fixtures, storage containers, trays, overhead fixtures,
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 of dirty floors, walls, fixtures, presence of rodent droppings, black substance on the ceiling, foods frozen to freezer floor and wall, dirty refrigerator floors.
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 stoves and ovens by POC due date. Administrator to submit a schedule of cleaning duty assignments and procedure to maintain accountability by POC due date 07/05/2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4