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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607592
Report Date: 02/04/2025
Date Signed: 02/05/2025 08:51:24 AM

Document Has Been Signed on 02/05/2025 08:51 AM - 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 CLARITAFACILITY NUMBER:
197607592
ADMINISTRATOR/
DIRECTOR:		COATES, RAINAFACILITY TYPE:
740
ADDRESS:24305 W LYONS AVETELEPHONE:
(661) 255-3100
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 99TOTAL ENROLLED CHILDREN: 0CENSUS: 53DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Raina CoatesTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness met with the interim Executive Director Raina Coates, 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 (53), which (17) 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. 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 November 26, 2024.

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, and 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. 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.
Bathrooms were checked for cleanliness and proper operations. Due to time constraints, LPA was not able to complete the annual inspection. LPA will return to complete a full inspection and audit of resident, staff, and medication records.
Exit interview and copy of report provided.
Troy AgardTELEPHONE: (818) -596-4334
Tuesday CabinessTELEPHONE: (818) 299-4975
DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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: 02/04/2025
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Due to time constraints, LPA was not able to complete the annual inspection. LPA will return to complete a full inspection and audit of resident, staff, and medication records.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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