197607592-10-14-2021-31-AS-ADUA-C7SV2D-20211014160259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607592
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:03:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 61	DATE:	10/14/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	JADE ALMA, Executive Director		TIME COMPLETED:	04:15 PM

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	LPA Abeye Duguma conducted a case management visit today on 10/14/21. LPA met with Executive Director (ED) Jade Alma and informed that the purpose of this case management visit was to follow up and gather additional information regarding two (02) separate incidents involving facility residents. The first Incident Report was received on 10/01/21 informing that on 09/25/21 a resident (R1) eloped from the facility. R1 was found and returned to the facility by police officers. The incident report indicates that police officers came to the facility to ask if a resident was missing, showed a picture of R1 and explained to the Staff that R1 was with the ambulance at a Wells Fargo Bank located across the street. During this visit at 11:10am LPA spoke with ED and was informed that R1 has dementia and lives with their spouse in the Assisted Living section. R1 has known wandering behavior and wears wonder guard bracelet. At the time of this visit, at 12:00pm LPA conducted a facility inspection and checked all exit doors leading out of the facility. Upon inspection, LPA discovered that out of the eleven (11) exits, five (05) were not in working condition and three (03) exits were not identified on the facility sketch. In addition, the wonder guard bracelets were checked and it was noted that of the 3 doors that have the wondering guard detectors, 2 were not recognizing and/or detecting the bracelets as designed. At 1:45pm LPA Duguma requested various facility records including specific documents from R1’s facility file. Based on the inspection, interviews and file review it was determined that additional investigation is required, and LPA will return at later time to complete the investigation of the elopement incident involving R1. The second incident Report was received 09/17/2021 regarding the incident of physical altercation between resident #2 (R2) and resident #3 (R3). Per incident report, on 09/15/2021, R2 and R3 were walking down the hall towards each in opposite directions. R2 approached R3, shaking their finger in R3's face and then pushed R3 to the ground. (Please see continuation page)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/14/2021

NARRATIVE

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No information was available regarding possible injuries to R3, resulting from the physical altercation.
During this visit at 2:30pm LPA spoke with ED and other staff. Interviews revealed that the two residents; R2 and R3 had an altercation earlier in the day in the hallway and were immediately separated. Hours later R2 and R3 met again and that is when the abuse took place. Staff indicted that no staff was present during second incident. The staff overheard the noise and rush to assist. Staff admitted that they were not able to reach residents on time to separate them. At the time of this visit at 3:05pm LPA Duguma inspected the facility, specifically the area where the incident happened. In addition, at 3:25pm LPA requested facility records for R2 and R3. Based on inspection, interviews and file review, it was determined that additional investigation is required and LPA will return at later time to complete the investigation of the Physical Altercation between R2 and R3.

Both incidents were discussed during this visit and ED was informed that during this visit LPA noted the deficiencies that could contribute to the outcome of both incidents.
All deficiencies noted during this visit will be addressed and citations will be issued at the time of completion of this case-management-incident visit.
Exit interview was conducted and a copy of 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: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC809 (FAS) - (06/04)

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