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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 04:24:03 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
10/30/2023 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 56-AS-20231030090247
FACILITY NAME:PACIFICA SENIOR LIVING HILLSBOROUGHFACILITY NUMBER:
361880893
ADMINISTRATOR:JENNIFER HELDOORNFACILITY TYPE:
740
ADDRESS:11918 CENTRAL AVENUETELEPHONE:
(909) 548-2100
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:156CENSUS: 115DATE:
02/10/2025
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director Isabel EnriquezTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Staff neglect resulted in a resident sustaining multiple pressure injuries
Staff mishandled a resident's medication while in care
Staff allows a resident to be soiled while in care
Staff left a resident unattended in the dark while in care
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 staff neglect resulted in a resident sustaining multiple pressure injuries, resident #1 (R1) in question was alleged to arrive to a medical facility with an injuries alleged to have originated from the facility. Interview with Memory Care Director (S1), states that R1 was cleaned and changed in the presence of R1's family member, with no noticeable injuries R1 upon discharge to a medical facility. Resident Service Director (S2), concurred that R1 did not have any pressure injuries upon discharge to the medical facility. LPA obtained R1's Physician Report that does not reveal any previous skin breakdown diagnosis.
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 56-AS-20231030090247
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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Regarding the allegation that staff mishandled, LPA Prieto obtained medication records for R1. The allegation stated that R1 was given antibiotics an those medications were given to facility but not dispensed. Medication records state that R1 was not prescribed this particular medication, which records appear to concur with statement. Interview with S1 and S2 both stated that antibiotics were brought to the facility with no doctor's order.

Regarding the allegation that staff allows resident to be soiled while in care, Interview with Memory Care Director (S1), states that R1 was cleaned and changed prior to leaving to a medical facility and no noticeable injuries R1 upon discharge to a medical facility. R1 was available for interview during time of investigation and could not observe or corroborate that resident was left in soiled diapers.

Regarding the allegation that staff left resident unattended in the dark while in care, due to R1 being available for interview during time of investigation, LPA could not observe or corroborate that resident was left unattended. No specific time periods were provided to investigate such allegation.

Based on the information obtained there is not enough evidence that staff neglect resulted in a resident sustaining multiple pressure injuries, staff mishandled a resident's medication while in care, staff allows a resident to be soiled while in care and staff left a resident unattended in the dark while in care. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive 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