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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425024
Report Date: 05/12/2022
Date Signed: 05/12/2022 09:42:33 AM


Document Has Been Signed on 05/12/2022 09:42 AM - 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: 68DATE:
05/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Julie OlmedoTIME COMPLETED:
09:46 AM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility regarding complaint number 56-AS-20220422090731. LPA Gardner met with Administrator Julie Olmedo and explained the reason for the visit.

LPA Gardner visited the facility to obtain a signature for amended reports.

An exit interview was conducted where this report was discussed and provided to the with Executive Director Julie Olmedo.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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