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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607592
Report Date: 11/09/2021
Date Signed: 11/09/2021 04:26:51 PM

Document Has Been Signed on 11/09/2021 04:26 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:MELANIE RIVERAFACILITY TYPE:
740
ADDRESS:24305 W LYONS AVETELEPHONE:
(661) 255-3100
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 99CENSUS: 65DATE:
11/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Jade Alma, Executive DirectorTIME COMPLETED:
04:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced Case Management visit to issue citations for deficiencies observed during the course of two (02) Incident Report investigations. LPA met with Jade Alma, Executive Director.

During the investigation, LPA observed the following:

1) Out of the eleven (11) exits, five (05) were not in working condition: Three (03) Egress and Two (02) Wandering Guard System Exits.

2) Facility failed to monitor/supervise residents closely after aggressive verbal altercation.

3) Three (03) exits were not identified on the facility sketch.

Pursuant to the California Code of Regulations, Title 22, the following deficiencies were observed and cited during the visit. Exit interview conducted, a copy of the report, citations, and appeal rights were issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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Document Has Been Signed on 11/09/2021 04:26 PM - It Cannot Be Edited


Created By: Abeye Duguma On 11/09/2021 at 02:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited

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87705 Care of Persons with Dementia (i) & (j) The licensee may use wrist bands or other egress alert devices... The licensee shall have an auditory device or other staff alert feature to monitor exits,.. This requirement is not met as evidence by: The Licensee did not ensure that the needs of dementia
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residents were properly addressed. Based on inspection and observation, the egress alarms were either not working or were not detecting the wander-guard bracelets as designed. This possess an immediate health and safety risk to residents in care.
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Type B
11/09/2021
Section Cited

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87705 Care of Persons with Dementia (b) (2) ...the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior...This requirement is not met as
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evidence by: The Licensee did not ensure that the needs of dementia residents were properly addressed. Based on inspection and observation, the licensee failed to ensure R1 and R2 was supervised by staff which poses an immediate health and safety hazard.
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Abeye Duguma
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/09/2021 04:26 PM - It Cannot Be Edited


Created By: Abeye Duguma On 11/09/2021 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2021
Section Cited

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87208 Plan of Operation(a) (7) (a) Each facility shall have and maintain a current, written definitive plan of operation. Any significant changes in the plan.. shall be submitted.. for approval.. shall contain the following: Sketches,.. dimensions, of the following:
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Building(s) to be occupied,.. floor plan…This requirement is not met as evidenced by; The licensee did not submit an updated facility sketch. Upon facility inspection it was noted that four (04) exits are not identified on the facility sketch.
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Abeye Duguma
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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