197607592-10-15-2021-31-AS-CHAS-CD24FX-20220330190439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607592
Report Date: 10/15/2021
Date Signed: 10/15/2021 01:45:12 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
06/17/2020 and conducted by Evaluator Wendell Smith

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20200617144106

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: 61	DATE:	10/15/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jade Alma		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff failed to note change in resident's medical condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with the administrator and explained the reason for this visit.
It is alleged that facility staff failed to note a change in resident # 1(R1) medical condition before R1 needed to be hospitalized. A previous visit was completed on 6/18/2020 where interviews were conducted with facility staff. Since that time interviews were conducted with R1, R1's personal caregivers, and facility staff. Interviews revealed that there was a stomach virus going around the facility in December 2019. On 12/27/19, R1 was seen by facility staff and their personal caregiver and was noted to be fine. On 12/28/19 R1 had symptoms consistent with a stomach virus. Interviews revealed that R1 did not report the symptoms to facility staff and did not call for assistance. Facility staff checked on R1 later in the day on 12/28/19 and R1 stated they were not feeling well and R1 was given some medication. During the investigation R1's medical records were also reviewed and did not show any sign of abuse or neglect from facility staff. Information obtained through interviews and a review of medical documentation show that

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

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-20200617144106

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: 10/15/2021

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	once facility staff became aware of R1's condition that the proper steps were taken. Based on the information obtained this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC9099 (FAS) - (06/04)

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