197607592-9-24-2024-31-AS-TAGD-D9TP2P-20241007105615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 09/24/2024
Date Signed: 09/24/2024 02:29:17 PM

Unsubstantiated

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
07/13/2023 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230713162106

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: 56	DATE:	09/24/2024
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Karen Enciso		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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1. Staff failed to seek timely medical attention for resident
2. Staff left resident soiled for an extended period of time

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent complaint visit and met with Regional Director of Operations Karen Enciso, and informed her the reason of the visit. The following was determined:

Allegation # 1: It was alleged staff failed to seek timely medical attention for resident. On 07/20/2023 from from 2pm to 3pm, LPA conducted the initial visit, and interviewed staff and obtained records pertaining to the allegation. During today's visit, from 1145am to 3pm, LPA conducted additional interviews and reviewed facility and resident documents. From the information obtained, resident # 1 (R1's) health began to rapidly decline, which caused mobility and gait issues. (R1) began to have a series of constant falls, and the facility contacted the primary physician, who ordered home health for physical therapy. The facility documented on medical and internal notes of (R1's) falls, which caused injuries. Interviews revealed staff contacted the paramedics on multiple occasions from (R1) being found on the floor or due to (R1) alerting staff with the emergency pendant. At the time of the visit, LPA was not able to interview (R1); it was reported

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

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-20230713162106

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: 09/24/2024

NARRATIVE

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(R1) passed away 08/2024. Therefore, based on interviews and documentation, the allegation is Unsubstantiated at this time.

Allegation # 2: It was alleged staff left resident soiled for an extended period of time. On 07/20/2023 from 2pm to 3pm, LPA conducted the initial visit, and interviewed staff and obtained records pertaining to the allegation. During today's visit, from 1145am to 3pm, LPA conducted additional interviews and reviewed facility and resident documents. From the information obtained, resident # 1 (R1's) health began to rapidly decline, which caused mobility and gait issues. Because of the (R1's) health issues, (R1) became incontinent and needed assistance for toileting. Interviews revealed (R1) would often be found by staff on the floor because of the fall, and (R1) would urinate or defecate on (R1's) clothing. Staff denied leaving (R1) soiled for periods of time. Therefore based on interviews and documentation the allegation is Unsubstantiated at this time.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC9099 (FAS) - (06/04)

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