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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 11/17/2021
Date Signed: 12/30/2021 03:37:44 PM



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
11/01/2021 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20211101135124
FACILITY NAME:PACIFICA SENIOR LIVING SANTA CLARITAFACILITY NUMBER:
197607592
ADMINISTRATOR:MELANIE RIVERAFACILITY TYPE:
740
ADDRESS:24305 W LYONS AVETELEPHONE:
(661) 255-3100
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY:99CENSUS: 65DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jade Alma, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility is not releasing resident's records to resident's responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to obtain additional information for the above noted allegations. LPA met with Jade Alma, Executive Director (ED). The purpose of the visit was discussed.

It was reported that facility did not to provide Resident #1’s (R1’s) records to the authorized representative in a timely fashion. To investigate these allegations, on 11/09/21 at 10am, LPA spoke to the ED who confirmed that they were aware of the request. However, due to administrative procedures, they did not provide the requested documents within the required time frame.

Based on the information revealed from the interview, this allegation is SUBSTANTIATED at this time.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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 2
Control Number 31-AS-20211101135124
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2021
Section Cited
HSC
11/27/2021
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§1569.269 (a) (21) Enumerated rights; severability to have prompt access to review all … records…and to purchase photocopies. Photocopied or residents’ records shall be promptly provided, not to exceed two business days, at a cost not
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The Licensee is going to provide a written plan of correction clearly explaining the step-by-step process to ensure that a similar problem does not happen again.
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to exceed the community standard for photocopies. This requirement is not met as evidenced by. The Licensee did not ensure that R1’s facility records are provided to the authorized representative in timely manner. This poses a potential personal right violation to residents in care.
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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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
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