197607592-10-14-2021-31-AS-NMAN-C8MU8Y-20211110142215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 09/14/2021
Date Signed: 10/14/2021 09:41:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/10/2021 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20210910084931

FACILITY NAME:	PACIFICA SENIOR LIVING SANTA CLARITA		FACILITY NUMBER:	197607592
ADMINISTRATOR:	MELANIE RIVERA		FACILITY TYPE:	740
ADDRESS:	24305 W LYONS AVE		TELEPHONE:	(661) 255-3100
CITY:	NEWHALL	STATE: CA	ZIP CODE:	91321
CAPACITY:	99	CENSUS: 57	DATE:	09/14/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Jade Alma		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident frequently elopes from the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Abeye Duguma, Rozaura Valenzuela and LPM Naira Margaryan conducted unannounced joint complaint visit to the facility.
LPAs and LPM met the Executive Director (ED) and explained the purpose of this visit.

During this investigation at 2:00pm LPA conducted a tour of the facility including bedrooms and common areas.
At 1:25pm LPAs spoke with ED and, at 2:20pm, LPAs spoke other facility staff. R1 was not in the facility at the time of vist. Interviews and record review revealed that R1 is an independent resident and can leave the facility unassisted.
In addition, at 1:50pm LPAs requested and reviewed R1’s facility files and other relevant documents.
A review of the documents verified the information received from interviews.
Based on the inspection observation, interviews and record review, there is no sufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time.
No health and safety hazard was noted during this visit.
Exit interview was conducted and a copy of the report was issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

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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