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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 01/24/2023
Date Signed: 01/24/2023 03:26:43 PM

Substantiated


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
01/18/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230118124221
FACILITY NAME:PACIFICA SENIOR LIVING SANTA CLARITAFACILITY NUMBER:
197607592
ADMINISTRATOR:JADE ALMAFACILITY TYPE:
740
ADDRESS:24305 W LYONS AVETELEPHONE:
(661) 255-3100
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY:99CENSUS: DATE:
01/24/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Jade AlmaTIME COMPLETED:
03:34 PM
ALLEGATION(S):
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Staff have not release resident's records to authorized representative in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with the Executive Director (ED), Jade Alma, and explained the reason for the visit.

--- Staff have not release resident's records to authorized representative in a timely manner
It was alleged that staff did not release Resident #1’s (R1) medical records timely. To investigate this allegation, on 01/24/2023, LPA interviewed the ED from around 12:30 PM – 1:30 PM and requested pertinent documents at around 1:45 PM. During the interview with the ED, they stated that documents were requested by R1’s responsible party on 01/12/2023, partially delivered on 01/16/2023 and completely delivered 01/18/2023. Record reviews confirmed that the requesting party is the person listed as the responsible party. Based on interview and record review, the allegation is substantiated at this time.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
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-20230118124221
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2023
Section Cited
CCR
87468.2(19)
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87468.2 (19) Additional Personal Rights of Residents in Privately Operated Facilities-To have prompt access to review all of their records .... within two (2) business and at a cost that does not... This requirement is not met as evidenced by:
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The Administrator will review regulation 87468.2 (19) Additional Personal Rights of Residents in Privately Operated Facilities and submit a written statement ensuring that they will adhere them.
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Based on interviews, the licensee did not ensure documentation of records were provided within 2 business days which posed a potential personal right violation to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2