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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425024
Report Date: 07/25/2022
Date Signed: 07/25/2022 01:14:03 PM


Document Has Been Signed on 07/25/2022 01:14 PM - 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: 66DATE:
07/25/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Julie Dion, Executive DirectorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Amy Goldenberg is conducting this unannounced visit to the facility for the purposes of a Plan of Correction (POC) visit, based upon the deficiencies cited on form LIC9099D issued on 07/01/2022.

During this visit LPA toured the kitchen and food storage areas. LPA observations verified the following:

*Deficiency 87555(b)(29) cited per Title 22 Division 6 of the California Code of Regulations has been cleared. Licensee complied with the terms of the POC.

*Deficiency 87555(b)(29) cited per Title 22 Division 6 of the California Code of Regulations has been cleared. Licensee complied with the terms of the POC.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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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