197607592-4-8-2025-31-AS-TAGD-DFMUY5-20250411155923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 04/08/2025
Date Signed: 04/08/2025 10:07:53 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
05/10/2023 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230510160400

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: 7	DATE:	04/08/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Angelica Quiblat		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident suffered multiple falls resulting in serious injuries

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to finalize the complaint investigation and deliver the final findings. LPA met with Business Office Manager Angelica Quiblat and explained the purpose of the visit.

On May 10, 2023, the Woodland Hills Regional South Adult and Senior Care Office received a complaint alleging that a resident (R1) suffered multiple falls resulting in serious injuries. The complaint was referred to the Community Care Licensing Division’s (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng for further review.

Between May 11, 2023, and August 10, 2023, Investigator Seng conducted an extensive investigation, which included interviews with facility staff, a review of documentation, and an examination of R1’s medical records. The following findings were determined: R1 experienced an initial fall on April 12, 2023, while at the facility, sustaining a neck laceration, cracked ribs, and head trauma. A second fall occurred on May 6, 2023, outside

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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 3

Control Number 31-AS-20230510160400

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING SANTA CLARITA	FACILITY NUMBER: 197607592
	VISIT DATE: 04/08/2025

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
26
27
28
29
30
31
32

of the facility at Walmart, resulting in a head laceration and a broken rib. R1 had been diagnosed with an unsteady gait and was recommended to use a wheelchair instead of a walker. Staff reported that R1 required a higher level of care and was often observed unsecured in bed, nearly falling. The facility did not reassess R1’s condition until after the second fall. Medical documentation indicated that R1 was no longer allowed to drive and leave the facility unattended. Based on the information gathered through interviews, documentation review, and direct observations, the Investigations Branch determined the facility failed to provide appropriate care and supervision to ensure R1’s safety, resulting in multiple falls and serious injuries. Therefore, the allegation is SUBSTANTIATED.

A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f)

Citation issued, appeal rights, exit interview conducted; and a copy of the report was issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230510160400

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 04/08/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/09/2025 Section Cited HSC 1569.49(f)	1 2 3 4 5 6 7	(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code to a resident, the civil penalty shall be ten	1 2 3 4 5 6 7	ED Raina Coates will discuss with corporate regarding the issue and the citation that was issued. Due to the facility is closing, RO will have to discuss what further action will need to take place regarding the civil penalty assessed and possible further action that maybe needed.
	8 9 10 11 12 13 14	thousand dollars ($10,000). This requirement was not met, evidenced by: based on the investigation conducted by IB; the facility failed to provide appropriate care and supervision to ensure R1’s safety, resulting in multiple falls and serious injuries. This is a health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3