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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425024
Report Date: 07/06/2022
Date Signed: 07/06/2022 09:47:26 AM


Document Has Been Signed on 07/06/2022 09:47 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:
07/06/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Julie Dion, Executive DirectorTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Amy Goldenberg arrived to the facility at 0900 to conduct a plan of correction visit. A complaint investigation visit was conducted on 07/01/2022 and the facility was cited per Title 22, Division 6 of the California Code of Regulations sections 87555(b)(29) and 87555(b)(27). LPA was provided with a request to extend the Plan of Correction (POC) for 87555(b)(27) via email on 07/05/2022. During the visit LPA verified that section 877555(b)(29) POC had been cleared. LPA notes that the broken salamander oven, steam cabinet, and refrigerator noted during the citing visit has been removed. LPA met with Julie Dion and discussed the request for extension 87555(b)(29). LPA was provided with a schedule for completion. A POC extension is granted and is extended to 07/13/2022.

This report was reviewed with and a copy was provided to Julie Dion, Executive Director.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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