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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607592
Report Date: 03/23/2023
Date Signed: 03/23/2023 01:50:14 PM


Document Has Been Signed on 03/23/2023 01:50 PM - It Cannot Be Edited

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 CLARITAFACILITY NUMBER:
197607592
ADMINISTRATOR:JADE ALMAFACILITY TYPE:
740
ADDRESS:24305 W LYONS AVETELEPHONE:
(661) 255-3100
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY:99CENSUS: 65DATE:
03/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jade AlmaTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a Case Management visit in conjunction with complaint# 31-AS-20230313124544 that was filed 03/13/2023. LPA met with the Executive Director (ED) Jade Alma and discussed the reason for the visit. During interviews, and documentation obtained, it was discovered that the facility did not report a fall or submit an incident report, that occurred 03/10/2023 involving Resident #1 (R1).

ED was made aware the POC will be cleared during today's visit, and any other incidents that are not reported to Licensing, will result in civil penalties.

Exit interview conducted and copy of reports and appeal rights issued.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/23/2023 01:50 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2023
Section Cited

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Reporting Requirements (a)... licensee shall furnish to the licensing agency such reports as the Dept. may require, including, but not limited to, the following: (1)... report shall be submitted to the... agency,,, within seven days of the occurrence…(B) Any serious injury...
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Executive Director has AGREED to submit incident report to LPA in regards to the incident that occurred with resident # 1 (R1) on 03/10/2023. Moving forward, any further incidents that are not reported to licensing
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occurring while the resident is under facility supervision. This requirement is not met as evidenced by; Based on record reviews and interview, the facility did not report a fall involving R1 to the Dept. which poses a potential Health and Safety risk to resident in care.
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will result in civil penalties. Incident report was submitted to LPA, and POC cleared.

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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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