197607592-1-14-2025-31-AS-TAGD-DDFQA6-20250131105925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:48:05 PM

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
01/06/2025 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250106141501

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: 53	DATE:	01/14/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Karen Enciso & Raina Coates		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Licensee is not ensuring facility elevator is operable for residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA)s Tuesday Cabiness and Angelica Segovia conducted an initial complaint visit to investigate the allegation mentioned above. LPAs was greeted by receptionist, who informed LPAs, the Executor Director Jade Alma is no longer at the facility and resigned. LPA contacted Director of Operations Karen Enciso, who reported corporate is in the process of transitioning regional positions and this time, there will be an interium ED who will be taking over. LPAs met with Resident Service Director Raina Coates and the following information was obtained during the visit.

From 945am to 130pm, LPAs conducted interviews and a physical plant inspection. The Regional Office received a complaint, pertaining to the one of the elevators not operating. LPAs conducted interviews and a physical plant inspection following a complaint received by the Regional Office regarding a non-operational elevator at the facility. During the inspection, it was confirmed that the elevator is not functioning, and corporate management is coordinating with their contracting company to repair the damaged part. Additionally, it was reported that another necessary part must be ordered to complete the repair. Residents interviewed stated

Substantiated

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: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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-20250106141501

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: 01/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/17/2025 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and operation: (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. It was confirmed that the	1 2 3 4 5 6 7	Regional Director of Operations Karen Enciso reported to LPA that the "repair is scheduled for ,Thursday 1/16/25, so long as we have a signed proposal & parts are received as anticipated". The RD will be in communication with LPA on the 16th. The POC will not be entirely cleared until the
	8 9 10 11 12 13 14	elevator is not functioning, and corporate management is coordinating with their contracting company to repair the damaged part. This is a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	elevator is 100% operating and functioning. The RD will communicate daily or weely with LPA regarding the repairs.
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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: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250106141501

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: 01/14/2025

NARRATIVE

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they must rely on staff assistance to transport them to the lower level of the facility for activities and dining. They reported experiencing delays while waiting for staff assistance. This situation poses a potential health and safety risk to residents in care. Based on the evidence obtained through interviews and the physical plant inspection, the allegation is Substantiated.

Exit interview, copy of report, appeal rights provided to Resident Services Director Raina Coates.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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