197607592-3-11-2022-31-AS-CHAS-CD24FW-20220330190438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 03/11/2022
Date Signed: 03/11/2022 10:25:21 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2020 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20200617144106

FACILITY NAME:	PACIFICA SENIOR LIVING SANTA CLARITA		FACILITY NUMBER:	197607592
ADMINISTRATOR:	MELANIE RIVERA		FACILITY TYPE:	740
ADDRESS:	24305 W LYONS AVE		TELEPHONE:	(661) 255-3100
CITY:	NEWHALL	STATE: CA	ZIP CODE:	91321
CAPACITY:	99	CENSUS: 71	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jade Alma		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff failed to adequately monitor resident resulting in hospitalization
Staff failed to seek resident timely medical attention
Staff failed to ensure that resident was adequately hydrated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to deliver findings regarding the allegations above. This complaint was referred to accepted by the Investigations Branch (IB). IB Investigator Edward Hector conducted the investigation.

Staff failed to ensure that resident was adequately hydrated
It is alleged that the facility failed to ensure that resident # 1(R1) was provided enough liquids due to R1 being dehydrated. R1’s medical records and facility records were obtained and reviewed over the course of this investigation. Interviews were conducted with R1, R1’s caretakers, and facility staff. Information obtained from interviews and records showed that R1 contracted a stomach virus on 12/28/21. During that time, facility staff checked on R1 to ensure their needs were being met. R1 stated that they never asked for assistance while sick. A review of medical records confirmed that R1 was dehydrated but did not show any signs of abuse or neglect. Based on the information obtained through interviews and record review, this allegation is deemed unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200617144106

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/11/2022

NARRATIVE

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Staff failed to seek R1 timely medical attention
It is alleged that facility staff failed to seek timely medical attention when R1 got sick with a stomach virus and that staff left R1 unattended for two days. R1’s medical records and facility file was obtained and reviewed. Interviews were conducted with R1, R1’s visitors, and facility staff. Information from interviews reveal that R1 came down with a stomach virus on 12/28/21 and needed to be hospitalized on 12/30/21. R1 did not initially inform the facility they were not feeling well. Facility staff found out during a routine check of R1. After the facility became aware that R1 had a stomach virus, R1 was put on a special diet. R1 confirmed that facility staff did indeed check on them on 12/28/21 and 12/29/21. On 12/30/21, a visitor came and saw R1 and observed R1 to have vomited and had a bowel movement on themselves. Information from interviews reveal that there is insufficient information to state that facility staff failed to seek timely medical attention for R1, therefore this allegation is deemed unsubstantiated at this time.

Staff failed to adequately monitor resident resulting in hospitalization
It is alleged that facility staff failed to monitor R1 resulting in R1 being hospitalized. Interviews were conducted with R1, R1’s visitors, and facility staff. R1’s hospital records and facility records were obtained and reviewed. Information obtained from R1’s facility records indicate that R1 got sick with the stomach virus on 12/28/21. On 12/28/21 and 12/29/21, facility staff checked on R1. R1 was also put on a special diet due to their stomach virus. Based on the information obtained through interviews and a review of R1’s facility file and hospital records, this allegation is deemed unsubstantiated at this time.

A copy of the report and appeal rights were delivered. Exit Interview conducted.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

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