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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607592
Report Date: 09/14/2021
Date Signed: 09/15/2021 06:59:25 AM

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: 57DATE:
09/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jade Alma, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Rosaura Valenzuela, Abeye Duguma, and LPM Naira Margaryan conducted an unannounced Case Management visit in conjunction with complaint control number 31-AS-20210106083354. The purpose of this Case Management visit is to issue citations for deficiencies observed during the course of the complaint investigation that is not directly related to the complaint. LPAs met with Jade Alma, administrator.

During the investigation, LPAs observed the following:

1) The door of the garbage chute was observed to be missing, creating a potential tripping hazard for the residents.

2) Room 117 was missing closet doors and bathroom floor was dirty.

3) Hot water was turned off and there was no accommodations for sanitary use of toilet and subsequent hand-washing for residents.

Pursuant to the California Code of Regulations, Title 22, the following deficiencies were observed and cited during the visit. Exit interview conducted, a copy of the report, citations, and appeal rights were issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CLARITA
FACILITY NUMBER: 197607592
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2021
Section Cited

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87307 Personal Accommodations and Services(d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
This requirement is not met as evidenced by:
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The hot water was turned off. This poses a potential health and safety risk to residents in care
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Type B
09/21/2021
Section Cited

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87307 Personal Accommodations and Services(d) The following space and safety provisions shall apply to all facilities: (3) All persons shall be protected against hazards within the facility.
This requirement is not met as evidenced by:
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LPAs observed a missing door on the second floor creating a potential tripping hazard for residents. Also, in room 117 LPAs observed missing closet doors. This poses a potential health and safety risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2