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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607592
Report Date: 04/23/2021
Date Signed: 04/23/2021 12:00:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PACIFICA SENIOR LIVING SANTA CLARITAFACILITY NUMBER:
197607592
ADMINISTRATOR:MELANIE RIVERAFACILITY TYPE:
740
ADDRESS:24305 W LYONS AVETELEPHONE:
(661) 255-3100
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY:99CENSUS: 47DATE:
04/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jade Alma/ AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Patrick Shanahan arrived at the facility in response to an Incident Report from 2/3/21. It was self reported that a resident received a bruise on their face due to staff hitting the resident.

LPA was able to interview the administrator, staff and attempted to interview the resident in question (R1). Interviews began at about 10:00 am. Facility staff informed the LPA that the staff in question (S1) was immediately removed from the facility pending their investigation. The internal investigation determined that S1 had not hit the resident, but S1 was removed from working with R1. Staff interviewed today also stated that S1 has never had complaints of abuse prior to the incident or after. S1 has since returned to work but does not work with R1.

LPA attempted to interview R1 at about 10:20 AM, however due to R1's cognitive abilities the interview was not possible.

LPA was able to gather R1's medical documentation, copies of interviews from the internal investigation and a copy of the information left by the local sheriff's department.

Based on information gathered from interviews, medical documentation, and from facility investigation notes, no citations or deficiencies will be issued. Exit interview conducted and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
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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