197607592-2-22-2024-31-AS-MVAO-D2QU37-20240223141303

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 02/22/2024
Date Signed: 02/22/2024 12:42:10 PM

Unsubstantiated

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
12/21/2020 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20201221121609

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: 63	DATE:	02/22/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Jade Alma, Executive Director		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff did not treat resident with respect

INVESTIGATION FINDINGS:

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At 10:20am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit at this facility to investigate the above allegation. LPA met with the Administrator and explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 10:30am, LPA requested resident and staff roster. At 10:40am, LPAs requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Menu, etc., relevant to the investigation. At approximately 10:50am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 11:00am – 12:30pm, LPA interviewed the Administrator, a Dining Service Director (S1), a cook, two (2) servers and six (6) out of seven (7) residents.
Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20201221121609

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: 02/22/2024

NARRATIVE

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Allegation: Staff did not treat resident with respect

It was alleged that on 12/21/20, facility served R1 with breakfast that R1 refused. Instead, R1 asked S1 to make something else, to which the cook replied that no other food was going to be made.

To investigate this allegation, at 11:00am, LPA made a visit to the kitchen and observed it is fully stocked with perishable and non-perishable foods. Interview with S1 and a cook revealed that the food is restocked regularly at least 2 times a week. LPA also observed the residents with special dietary needs are posted in the kitchen prep area with pictures of the resident and their food choices or required preparation. Interview with the Executive Director, S1, a cook and two (2) servers revealed that the facility has a daily menu for breakfast, lunch, and dinner and during each meal the menu is placed on a dining table for residents to choose from. All parties interviewed, informed LPA that if residents don’t desire the item on the menu, they can request an alternative option/choice. Moreover, interview with S1 and a cook revealed that they will always make necessary changes and both staff denied the above allegation. In addition, LPA conducted an interview with six (6) residents and all residents confirmed that the facility's S1 and a cook will make necessary changes upon resident's request. All residents interviewed expressed no concern regarding the above allegation. Based on observation and interviews there is no sufficient evidence to support the allegation. Therefore, this allegation is Unsubstantiated at this time.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC9099 (FAS) - (06/04)

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