197607592-2-25-2022-31-AS-NMAN-CDLU23-20220418151117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 02/25/2022
Date Signed: 02/25/2022 02:31:25 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
11/02/2020 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20201102170658

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:	02/25/2022
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Jade Alma		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Administrator is overcharging resident in retaliation
Administrator failed to obtain proper signature from resident on admission agreement

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Abeye Duguma conducted a subsequent complaint visit to the facility.
LPA met with the Administrator Jade Alma and explained the reason for the visit.
--- Administrator is overcharging resident in retaliation
It was reported that the facility is trying to extort money from Resident #1 (R1) for shower and tray services.
To investigate this allegation on 02/23/2022 at 11:30am, LPA interviewed staff and requested pertinent documents. Upon review, LPA discovered that the only additional charges that the resident incurred, outside of shelter expenses and late fees, were for room service fees that were charged to the resident for Tray Service. The Admissions Agreement clearly states that, "The dining room staff may provide catering services for the Resident in his/her Apartment or in a common area with adequate notice to and approval by the Executive Director and Dining Services Director and the payment of an ADDITIONAL FEE."
Based on the interview and record review, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.
(CONT. on LIC9099-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: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

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 31-AS-20201102170658

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: 02/25/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

---Administrator failed to obtain proper signature from resident on admission agreement

It was reported that the resident did not sign the admission agreement. To investigate this allegation on 02/23/2022 at 11:00am, LPA requested pertinent documents. Upon review, LPA discovered that the Admissions Agreement was signed and dated by the resident's responsible party in all appropriate sections.
Based on the record review, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.
No heath and safety hazards noted during this visit.
Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2