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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 03/23/2023
Date Signed: 03/23/2023 02:35:19 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
03/13/2023 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230313124544
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
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jade AlmaTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff did not assist resident in a timely manner after a fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director Jade Alma and informed her the reason of the visit. The following was determined:

It was alleged that staff did not assist resident in a timely manner after a fall. On March 15, 2023 and March 21, 2023, from 9am to 11pm, LPA attempted to contact the complainant, pertaining to the allegation. During the visit on 03/21/2023 from 1030am to 1pm, LPA obtained and reviewed facility and resident records and conducted interviews with residents and staff. But due to technical issues with computer, LPA was not able to deliver the complaint at the time of the visit. But according to information obtained, on March 10, 2023, resident #1 (R1) fell in the early morning and pressed the facility’s call button; but got no response from staff. R1 crawled to the hallway on the 2nd floor and asked for assistance from resident # 2 (R2). It was reported to LPA that R2 attempted to use the facility’s telephone in the hallway; but did not get any response from staff. R2, used the elevator to the main lobby, to seek assistance for R1. LPA determined that there was a period of over approximate (45) minutes, before staff arrived to assist R1.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20230313124544
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: 03/23/2023
NARRATIVE
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Documentation obtained also reported the same time frame. Based on interviews and documentation, the allegation is Substantiated at this time. This is potential health and safety risk to residents in care.

Exit interview, citation issued; appeal rights and copy of report provided.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230313124544
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: 03/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities ;(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) to be accorded safe, healthful and comfortable
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Executive Director has AGREED to ensure staff will continue to provide consistent and frequent rounds of all residents in care. ED will submit to LPA by a written templete of round checks by 03/27/2023. On04/05/2023, ED
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accommodations, furnishings and equipment. This requirement was not met, evidenced by; based on interviews R1 fell and staff did not assist in a timely manner. This is a potenital health and safety risk to residents care.
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will submit documentation of staff signatures and round checks, from 03/27/2023 through 04/04/2023.
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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: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/13/2023 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230313124544

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
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jade AlmaTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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1. Staff do not ensure that resident has a working call button
2. Staff failed to administer resident's medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness met with Executive Director (ED) Jade Alma and informed her the reason of the visit. The following was determined:

Allegation # 1: Staff do not ensure that resident has a working call button. It was alleged that staff do not ensure that resident has a working call button. On March 15, 2023 and March 21, 2023, from 9am to 11pm, LPA attempted to contact the complainant, pertaining to the allegation. During the visit on 03/21/2023 from 1030am to 1pm, LPA obtained and reviewed facility and resident records and conducted interviews with residents and staff. But due to technical with computer, LPA was not able to deliver the complaint at the time of the visit. But according to information obtained, it was reported to LPA by residents, the issue is not the call button does not work; it’s the amount of time it takes for staff to respond. Some residents stated, they have waited for more than (15) mins to get assistance from staff, especially during the late-night hours. It was also reported to LPA by staff that there are times when residents don’t press the button hard to register for assistance. Therefore, based on interviews, the allegation is Unsubstantiated at this time.





Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230313124544
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: 03/23/2023
NARRATIVE
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Allegation # 2: Staff failed to administer resident's medications as prescribed

It was alleged that staff failed to administer resident’s medication as prescribed. On March 15, 2023 and March 21, 2023, from 9am to 11pm, LPA attempted to contact the complainant, pertaining to the allegation. During the visit on 03/21/2023 from 1030am to 1pm, LPA obtained and reviewed facility and resident records and conducted interviews with residents and staff. But due to technical with computer, LPA was not able to deliver the complaint at the time of the visit. But according to information obtained, resident #1 (R1) was self-administering R1’s own medication. Within the last month, staff noticed a change in R1’s condition pertaining to R1’s medication, and the facility conducted a family conference regarding the concerns about R1’s condition. Facility contacted the primary doctor and conducted an assessment on R1 pertaining to self-administering medication. Facility concluded, it was in the best interest medication should be administered by the facility; except for (1) medication, which everyone agreed, R1 would continue to self-administer. Therefore, based on interviews, LPA doesn’t have sufficient evidence to prove the allegation, and it’s Unsubstantiated at this time.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5