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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366425024
Report Date: 04/28/2022
Date Signed: 04/28/2022 01:31:21 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
04/22/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220422090731
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: 86DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH: Julie OlmedoTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility has pests.
Facility not maintained clean and sanitary.
Facility kitchen stores foods that are not safe for consumption.
Facility does not provide food service personnel with food service training.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility for the purpose of initiating and delivering findings on the above complaint allegations. LPA Gardner met with Executive Director Julie Olmedo.

LPA Gardner toured the facility, reviewed facility documentation, and conducted interviews with kitchen staff and residents.

Regarding the allegations “Facility has pests”, “Facility not maintained clean and sanitary” and Facility kitchen stores foods that are not safe for consumption.”:
LPA Gardner was informed by Administrator Julie Olmedo that the facility is contracted with Dewey Pest Control that services the facility once a month. LPA Gardner reviewed the pest control invoices dated from January 2021 to April 2022.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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-20220422090731
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: 04/28/2022
NARRATIVE
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The invoices state a monthly service is being completed, but they are not specific to what type of treatment is being completed. During the tour of the kitchen, LPA Gardner observed the kitchen floors to have fresh food and dried up food stuck on the floor throughout the kitchen. There were mouse droppings throughout the kitchen floor where food is being prepped. There were mouse droppings on the cutting boards and the surrounding cabinet area where the cutting boards are being stored. There were mouse droppings on the storage cabinet that contains canned food that is served to residents. The general consensus is that the pest control service has not been effective in the kitchen, cleaning in the kitchen is not being maintained properly to keep pests out of the kitchen, and there is currently a problem with pests. LPA Gardner also found that the kitchen staff had pre prepped bowls of ice cream and placed the tray inside the freezer without covering or dating the food.

Regarding the allegation, “Facility does not provide food service personnel with food service training”:

The facility has a full time cook on site, but does not have a nutritionist, a dietitian, or a home economist on site at the facility and could not giver proper documentation of the dates and times visits had occurred by one of the listed professions.

The allegations listed above are SUBSTANTIATED. A finding that the allegations are SUBSTANTIATED means that the allegations are valid because there is a preponderance of the evidence the standard has been met.

The facility is being cited for three (3) type A deficiencies and one (1) type B deficiency during today’s visit. An exit interview was conducted where this report was discussed and provided to the with Executive Director Julie Olmedo, along with a copy of the appeal rights.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20220422090731
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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
87555(b)(27)
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(b)The following food service requirements shall apply:(27)All kitchen areas shall be kept clean and free of litter, rodents.. Based on observation and interview, the licensee did not comply with the section cited above by not keeping the kitchen clean of litter on the floor and mouse droppings.
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The administrator needs to read regulation 87555 entirely and send self-certify letter to LPA by email or stamped mail. The administrator needs to send picture proof to LPA.
Type A
04/29/2022
Section Cited
CCR
87555(b)(9)
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(b)The following food service requirements shall apply:(9)Procedures...protect the safety, acceptability/nutritive values of food.. observed in food storage, preparation and service. Based on observation and interview, the licensee did not comply with the section cited above by having mouse droppings were food is stored and served to residents.
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The administrator needs to read regulation 87555 entirely and send self-certify letter to LPA by email or stamped mail. The administrator needs to send picture proof to LPA that the kitchen floors, storage, and cabinets have been cleaned and removed of dried food and mice droppings.
Type B
04/29/2022
Section Cited
CCR
87555(b)(17)
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b)The following food service requirements shall apply:(17)In facilities licensed for fifty (50) or more... a full-time employee qualified... responsible for the operation of the food service...
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The administrator needs to read regulation 87555 entirely and send self-certify letter to LPA by email or stamped mail. The administrator needs to send proof that a quailfied employee will be on site.
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Based on observation, record review and interview, the licensee did not comply with the section cited above by not having a dietitian on site and by not having proof of visits from a dietitian.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20220422090731
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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
87555(b)(23)
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(b)The following food service requirements shall apply:(23) All readily perishable food...shall be stored in covered containers at appropriate temperatures.
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The administrator needs to read regulation 87555 entirely and send self-certify letter to LPA by email or stamped mail.
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Based on observation and interview, the licensee did not comply with the section cited above by having uncovered pre prepped ice cream in the freezer.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4