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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609638
Report Date: 09/19/2021
Date Signed: 09/19/2021 03:00:05 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
07/27/2020 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20200727084814
FACILITY NAME:PACIFICA SENIOR LIVING NORTHRIDGEFACILITY NUMBER:
197609638
ADMINISTRATOR:VILLASENOR, LISAFACILITY TYPE:
740
ADDRESS:8700 LINDLEY AVETELEPHONE:
(818) 886-5181
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:0CENSUS: 81DATE:
09/19/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Francis Norberte, Memory Care DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not seek appropriate medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint visit to deliver the final report of the complaint investigation initiated on 08/05/2020.

It was reported that resident #12 (R1) was having confusion and hallucinations and that facility did nothing about it.

To investigate the allegation on 08/05/2020 LPA Maragaryan spoke with the ED and she stated that R1 was released from the hospital to the facility on 07/22/2020. Upon admission they noticed that R1 started declining very fast and on 07/23/2020, R1 started to receive Hospice services. The hospice nurses were in the facility around the clock. R1's family visited R1 on 07/24/2020 and as per family's request R1 was sent to the hospital.

A review of facility records conducted on 09/05/2020, verified that while in the facility R1 was having shortness of breath and was agitated. See 9099C to continue
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2021
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-20200727084814
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 NORTHRIDGE
FACILITY NUMBER: 197609638
VISIT DATE: 09/19/2021
NARRATIVE
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Hospice personnel were present in the facility and R1 was monitored around the clock.

The information revealed from record review, verified the information revealed from the interview. No pertinent information was available to the support the allegation. Therefore, the allegation, is UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2