197607592-10-26-2022-31-AS-RRAZ-CL3PM8-20221111102554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 10/26/2022
Date Signed: 10/26/2022 03:51:42 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
09/12/2022 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20220912161042

FACILITY NAME:	PACIFICA SENIOR LIVING SANTA CLARITA		FACILITY NUMBER:	197607592
ADMINISTRATOR:	JADE ALMA		FACILITY TYPE:	740
ADDRESS:	24305 W LYONS AVE		TELEPHONE:	(661) 255-3100
CITY:	NEWHALL	STATE: CA	ZIP CODE:	91321
CAPACITY:	99	CENSUS: 72	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Jade Alma		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Due to lack of supervision resident was physically assaulted by another resident.
Staff did not report unusual incident to resident's representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (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 10:00am.

---Due to lack of supervision resident was physically assaulted by another resident.

It was alleged that resident #3 (R3) shoved resident #1 (R1) into a wall which resulted in a head injury and that R3 assaulted resident #2 (R2). To investigate the allegation, on 09/14/2022, LPA interviewed five (05) staff from 12:00 PM - 3:00 PM and on 10/26/2022 at 12:30 PM, LPA attempted to interview R1 and R2, but they did not respond to any questioning and LPA was unable to interview R3 as they are deceased. On 10/26/2022 at 3:00PM LPA received and reviewed other records. During interviews with staff, Staff #1 (S1) stated that they did not witness R3 push R1 or assault R2, but heard that Staff #2 (S2) witnessed the altercation between R1 and R3. (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: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

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-20220912161042

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: 10/26/2022

NARRATIVE

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When LPA interviewed S2, they stated that they did not witness R3 push R1 or assault R2. During interviews with Staff #3 (S3), they stated that no one witnessed R1 fall and they are not aware of R1 being pushed, but did confirm that there was an altercation between R2 and R3 which resulted in hospitalization. Staff #4 and #5 (S4 and S5) also stated that they did not witness R3 push R1 or assault R2 and that they only heard about it from other staff. Other records revealed that staff were assisting other residents when R2 and R3 exchanged words and within seconds R2 assaulted R3 and R3 pushed R2 to the ground in defense. Staff attempted to catch R2 but could not reach them in time and staff immediately intervened by separating the residents and called 911.

Based on interviews and other sources, there is not enough information to verify the allegation, therefore, the allegation is unsubstantiated at this time.

--- Staff did not report unusual incident to resident's representative.

It was alleged that staff did not report the physical incident that occurred between R1 and R3 to their families. To investigate the allegation, on 09/14/2022, LPA requested and reviewed records at 11:00 AM and interviewed five (05) staff from 12:00 PM - 3:00 PM. Interviews with staff revealed that the allegation of R3 pushing R1 was all based on hearsay and the unusual incident could not be confirmed, therefore, the facility could not report any such incident to their families.

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

Although the above allegation is deemed unsubstantiated, interviews with S3 revealed that the R1 did fall and was hospitalized. During record reviews it was discovered that the facility did not notify the Department of R1’s fall and therefore a Case Management visit will be completed to address the issue.

No safety hazards noted during the 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: 10/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022

LIC9099 (FAS) - (06/04)

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