197607592-1-24-2022-31-AS-NMAN-CBC2Q4-20220204163520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 01/24/2022
Date Signed: 01/24/2022 05:41:59 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
08/19/2019 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20190819165417

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: 67	DATE:	01/24/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Jade Alma, Executive Director		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Neglect led to resident falling

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Abeye Duguma conducted unannounced subsequent complaint visit to the facility. On 01/03/2022 at 10:00am, LPA met with the Executive Director (ED), Jade Alma, and explained the purpose of this visit. It was alleged that neglect led to resident falling multiple times. To investigate this allegation, on 08/21/2019, LPA Christopher Harriel gathered pertinent documents, spoke with facility staff and other parties. Interviews revealed that facility staff were well aware of R1 being prone to falling and needing close supervision to prevent falls. On 01/03/2022 at 10:30am, LPA Abeye Duguma reviewed incident reports subsequent to the complaint and discovered that R1 continued to reside at the facility and suffered from another fall incident resulting in injury. The record review also revealed that R1 was documented as a fall risk and there were no updated Needs and Services Plan or Care Plan for R1 to address the number of falls R1 sustained during their time at the facility. The facility did not monitor R1 closely enough to avoid falling and/or injuries. Therefore, based on interviews and record review, the allegation is Substantiated at this time. No other health and safety hazards observed during the visit. Deficiencies cited on LIC 9099-D. Appeal Rights explained. Exit interview conducted and a copy of the report was issued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

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-20190819165417

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: 01/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/04/2022 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	Basic Services: ....if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457......either directly or through outside resources.	1 2 3 4 5 6 7	A plan will be developed to safeguard and reassessed residents for appropriate placement.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by; Based on interviews and record review, facility did not meet R#1’s needs to keep them safe when they were identified as a fall risk and R1 had subsequent falls where they sustained injury.	8 9 10 11 12 13 14
Type B 02/04/2022 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	Reappraisal: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.	1 2 3 4 5 6 7	The facility will develop a plan to address reappraisals of residents prior to their return to the facility from hospitals.
	8 9 10 11 12 13 14	This require is not met as evidenced by; Based on interviews and record review, facility did not conduct a reappraisal to address R1's change in condition.	8 9 10 11 12 13 14

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022

LIC9099 (FAS) - (06/04)

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