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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880893
Report Date: 02/10/2025
Date Signed: 02/10/2025 03:45:41 PM

Unsubstantiated


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
11/18/2021 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 18-AS-20211118151519
FACILITY NAME:PACIFICA SENIOR LIVING HILLSBOROUGHFACILITY NUMBER:
361880893
ADMINISTRATOR:TAYLOR, MANDYFACILITY TYPE:
740
ADDRESS:11918 CENTRAL AVENUETELEPHONE:
(909) 548-2100
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:156CENSUS: 115DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Isabel Enriquez, Executive Director TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident's call button is in disrepair
Facility is not following admission agreement
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) Javier Prieto arrived at the facility to conduct a complaint investigation regarding the aforementioned allegation. LPA Prieto met with Executive Director Enriquez, who provided a comprehensive explanation of the complaint elements.Regarding the allegation that a resident's call button is in disrepair, Director Enriquez and LPA Prieto toured the memory ward of the facility and interviewed residents R1, R2, R3, and R4.
All residents stated that they have not used their call buttons and that staff are always available to assist when needed. The call buttons in this complaint refer to the pull cords in each resident's room. LPA Prieto observed four additional resident rooms and found that none of the call pull cords were in disrepair. LPA Prieto also obtained an Activity Device Report, which monitors response times to all residents at the facility, with an average response time of four minutes.

Regarding the allegation that the facility is not following the admission agreement, Director Enriquez provided the needs and care plan for resident R5, who was in question. The allegation stated that R5 was not
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
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 2
Control Number 18-AS-20211118151519
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 HILLSBOROUGH
FACILITY NUMBER: 361880893
VISIT DATE: 02/10/2025
NARRATIVE
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assessed as a fall risk and that status checks were not conducted. However, the needs and services plan indicates that R5 was assessed as a fall risk and that status checks of four per shift were mandated. R5 was not available for an interview at the time of the initial complaint investigation.

Based on the information obtained, there is not enough evidence to substantiate the claims that the resident's call button is in disrepair or that the facility is not following the admission agreement. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Director Enriquez, and a copy was left with the facility.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2