197607592-4-5-2022-31-AS-NMAN-CEPV2C-20220523160253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 04/05/2022
Date Signed: 04/05/2022 05:42:21 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
02/28/2022 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20220228132414

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:	04/05/2022
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Jade Alma		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff overdosed resident
Staff failed to meet resident's needs

INVESTIGATION FINDINGS:

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

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 overdosed resident

It was alleged that Resident #1 (R1) overdosed on Lithium medication and found Marijuana in the R1’s system. To investigate this allegation, on 03/08/2022 at 11:00 AM, Licensing Program Analysts (LPAs) Gary Tan and Abeye Duguma requested pertinent documents and interviewed staff between 11:30 AM - 3:00 PM. On 03/08/2022 at 12:30 PM, LPAs interviewed the on-duty Med Tech and it was discovered that R1 does not have access to medications and that all of R1’s medications are administered by the on-duty Med Tech.

(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)

Page: 1 of 2

Control Number 31-AS-20220228132414

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

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

A record review also revealed that R1 has a history of drug abuse and the Medication Administration Records (MARs) agree with the doctor’s prescription.

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

--- Staff failed to meet resident's needs.

It was alleged that the R1's laundry, medication, hygiene and nutrition needs are not being met. To investigate this allegation, on 03/08/2022 Licensing Program Analysts (LPAs) Gary Tan and Abeye Duguma conducted a physical inspection of randomly selected rooms and interviewed staff between 11:30 AM - 3:00 PM. On 03/08/2022 at 11:45pm, LPAs observed that each resident has a separate laundry basket and interviews revealed that laundry is done once a week or as needed. On 03/08/2022 at 12:30 PM, LPAs interviewed the on-duty Med Tech and it was discovered that R1 does not have access to medications and that all medications are administered timely. On 03/08/2022 at 2:00 PM, LPAs interviewed staff and on 04/05/2022 at 11:00 AM LPA interviewed residents who all verified that all hygiene needs are being met, that caregivers are on standby for those who need assistance and that all meals are served timely with the option of Tray/Room Service.

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

No health and safety hazards were noted during the visit.

Exit interview was 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: 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 2