197607592-4-5-2022-31-AS-NMAN-CDLP39-20220418105709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 04/05/2022
Date Signed: 04/05/2022 05:44:57 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, 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
08/19/2020 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20200819143612

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:	DATE:	04/05/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jade Alma		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff is not meeting resident's dietary needs while in care
Staff are not responding to residents timely while in care
Staff do not have planned activities for residents
Administrator failing to allow health care of choice.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. Upon entry, LPA met with Executive Director (ED), Jade Alma, and explained the reason for the visit. A physical plant tour was conducted at 9:45am.

--- Staff is not meeting resident's dietary needs while in care.

It was alleged that the facility does not effectively coordinate Resident #1’s (R1) meals with their insulin administration.To investigate this allegation, on 02/09/2022 LPA interviewed the ED and requested pertinent documents from 11:30 AM - 12:00 PM. On 03/30/2022, LPA interviewed staff and residents from 11:00 AM - 2:30PM. Interviews with staff and residents revealed that all residents have access to the dining area from 7:00am – 7:00pm where they can request meals and snacks as needed.

(CONT. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

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-20200819143612

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: 04/05/2022

NARRATIVE

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Furthermore, it was discovered that resident and their responsible parties are allowed to bring food and snacks for residents to keep in their rooms.

Based on the interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Staff are not responding to residents timely while in care.

It was alleged that the caregivers do not provide care in a timely manner because the facility is understaffed. To investigate this allegation, on 03/30/2022, LPA interviewed staff and residents from 11:00 AM - 2:30PM. I addition, on 03/30/2022 at 1:30 PM LPA conducted a pendent test and made observations. Observations, along with Interviews of staff and residents revealed that staff are able to respond to residents timely and that in the event of an emergency, residents have access to a pendent which when triggered, staff respond immediately.

Based on the interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Staff do not have planned activities for residents.

It was alleged that there are minimal activities and that the facility did not have acceptably safe activities for residents during the COVID-19 pandemic. To investigate this allegation, on 02/09/2022 LPA interviewed the ED and requested pertinent documents from 11:30 AM - 12:00 PM. On 03/30/2022, LPA interviewed staff and residents from 11:00 AM - 2:30PM. Interviews with staff and residents revealed that all residents have access to a multitude of planned activities which are posted monthly in plain sight and printed daily and distributed. Interviews also revealed that the unforeseen COVID-19 pandemic did affect the activities but did not eliminate them. The activities during the pandemic were modified in a way that allowed social distancing to mitigate the spread of COVID-19.

Based on the interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
(CONT. on LIC 9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20200819143612

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: 04/05/2022

NARRATIVE

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---Administrator failing to allow health care of choice.

It was alleged that the facility is not allowing R1 to use health care provider of choice. To investigate this allegation, on 02/09/2022 LPA interviewed the ED from 11:30 AM - 12:00 PM. On 03/30/2022, LPA interviewed staff and residents from 11:00 AM - 2:30PM. Interviews with staff and residents revealed that all residents are free to use any health care provider of their choice. None of the residents that were interviewed felt that they were being forced or pressured into using a health care provider suggested by the facility.

Based on the interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022

LIC9099 (FAS) - (06/04)

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