197607592-9-15-2021-31-AS-NMAN-CA6T3J-20211229132225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 09/14/2021
Date Signed: 09/15/2021 07:01:37 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
01/06/2021 and conducted by Evaluator Rosaura Valenzuela

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210106083354

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:	01:12 PM
MET WITH:	Jade Alma, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff neglect resulted in resident's death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a subsequent complaint visit to deliver the findings for the above noted allegation. LPA met with Jade Alma, Administrator. The purpose of the visit was discussed. The investigation of the above noted allegation was conducted by Investigator Christine Ferris from the Community Care Licensing Division Investigations Branch (CCLDIB).
Allegation-Staff neglect resulted in resident’s death
It was alleged that Resident #1 (R1)’s death was the result of staff neglect. To investigate this allegation, the investigator reviewed medical records on 3-08-21. Medical records revealed that R1 passed away at the hospital from cardiopulmonary arrest. There was no prior history of the health condition(s) that may contribute to R1’s death.
The investigator conducted interviews with the staff between 2-01-21 and 3-16-21. Interviews revealed that on 12-27-20, R1 complained of chest pain and 911 was called. R1 was transported and admitted the hospital. Prior to the medical emergency, R1 did not complain to staff of chest pain, shortness of breath, or of any other pain. See continuation on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
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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Control Number 31-AS-20210106083354

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CLARITA	FACILITY NUMBER: 197607592
	VISIT DATE: 09/14/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on information obtained from interviews and record review, there is insufficient evidence to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
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

LIC9099 (FAS) - (06/04)

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