197607592-3-30-2022-31-AS-NMAN-CDLP3A-20220418105709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 03/30/2022
Date Signed: 03/30/2022 05:47:20 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: 73	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Jade Alma, Executive Director		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff is not following admission agreement
Staff fails to properly maintain the facility

INVESTIGATION FINDINGS:

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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.
--- Staff is not following admission agreement
It was reported that resident #1’s (R1) rent was suddenly increased by eighty-four percent (84%).
To investigate this allegation on 02/09/2022 at 10:45am, LPA conducted interviews and requested pertinent documents. Upon review, LPA discovered that the only additional charges that the resident incurred, outside of shelter expenses (and the historical five percent annual increase) 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: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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: 03/30/2022

NARRATIVE

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--- Staff fails to properly maintain the facility

It was reported that the shower is often filthy and sometimes has feces on the floor. To investigate this allegation on 03/30/2022, from 11:00am – 2:30pm, LPA conducted a physical plant tour to inspect rooms at random and conducted interviews with both residents and staff. During the inspection, all shower floors were observed to be clean and all residents and staff stated that the shower floors are clean and well maintained.
Based on the observations and interviews, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

No health 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: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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