197607592-6-17-2024-31-AS-TCAS-D6BTU9-20240617150158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607592
Report Date: 06/17/2024
Date Signed: 06/17/2024 03:03:56 PM

Document Has Been Signed on 06/17/2024 03:03 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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: 62	DATE:	06/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jade Alma		TIME COMPLETED:	03:15 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	Licensing Program Analyst (LPA) Tuesday Cabiness met with the Jade Alma, the Executive Director and informed her the reason of the visit; which is to conduct an annual inspection. The facility physical plant consists of the front lobby area, that includes the Administration offices, staff break room, dining and activity room, library, receptionist, movie theater, beauty salon, and laundry room. The current census is (62), which (13) consist of memory care residents. A tour of the physical plant was conducted which included common areas, resident bedrooms and bathrooms and their personal accommodations. The rooms were observed to have the appropriate furniture and the bathrooms had the required grab bars and shower chairs and non-skid mats. The hot water was tested in randomly selected resident rooms. Resident rooms have a kitchenette and microwave that is provided. The facility maintains a comfortable temperature, and rooms have private heating and air. The smoke and carbon monoxide detectors are hardwired and interconnected. Fire extinguishers are located throughout the facility, observed to be full and last inspected on August 2023. The kitchen was observed for food supply and the service area including the dining section. It was observed to have sufficient amount of perishable and non perishable food and each table was set up with salt pepper, sugar, nd other items needed to add to their meals. The menu was observed to be of quality and quantity to meet the residents needs. There is a set menu of daily meals and there is always an alternative menu that is available to the residents which they can order from any day and for any meal. Food Service/Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives are properly locked and secured in the kitchen storage area. Cleaning and housekeeping supplies are locked and stored separately from the kitchen area.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

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
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: 06/17/2024

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The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at an average of 120°F. There was enough clean linen available in the residents' rooms.

Medication room was locked and inaccessible to residents. There is a complete first aid kit at the facility.

Residents and staff records were reviewed. LPA reviewed files of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appear to be given as prescribed. Residents files appear to be complete and updated. Staff present files were also reviewed, staff files appear to be complete and updated training. No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024

LIC809 (FAS) - (06/04)

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