197610025-10-2-2023-31-AS-NMAN-CWNTQ7-20231016145529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610025
Report Date: 10/02/2023
Date Signed: 10/02/2023 03:55:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
11/17/2022 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20221117155044

FACILITY NAME:	PACIFICA SENIOR LIVING NORTHRIDGE		FACILITY NUMBER:	197610025
ADMINISTRATOR:	VILLASENOR, LISA		FACILITY TYPE:	740
ADDRESS:	8700 LINDLEY AVENUE		TELEPHONE:	(818) 886-5181
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	110	CENSUS: 89	DATE:	10/02/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Lisa Villasenor		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff does not serve residents a sufficient amount of food
Facility staff serves residents cold food

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 9:35 a.m. on 10/02/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Administrator and disclosed the reason for the visit.

To investigate the allegations above, LPA toured the physical plant at 9:45 a.m. and 12:00 p.m. today, reviewed the staff list and resident list at 10:00 a.m., and interviewed 10% of staff and 10% of residents between 10:10 a.m. and 12:30 p.m.

Regarding the allegation “Facility staff does not serve residents a sufficient amount of food” it was alleged that the facility would not provide additional food when residents requested more. Interviews with the Administrator at 11:45 a.m. and Staff #1 (S1) at 12:05 p.m. today revealed the facility provides a wide variety of food options in their daily menu and alternative menu.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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-20221117155044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING NORTHRIDGE	FACILITY NUMBER: 197610025
	VISIT DATE: 10/02/2023

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

Additionally, when residents request more food or alternative food, and the facility provides them. Resident interviews between 10:10 a.m. and 11:25 a.m. today revealed no issues with food portions provided or the ability to obtain more food. During the physical plant tour with the Administrator at 12:00 p.m. today, LPA observed the main menu with two options and two alternate menus posted in the dining room. LPA also observed the lunch service at 12:05 p.m. and saw sufficient quantities of food served to residents. Based on interviews and observations, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Regarding the allegation “Facility staff serves residents cold food” it was alleged that the food served is not an adequate temperature. Resident interviews between 10:10 a.m. and 11:25 a.m. today revealed residents were aware that the facility can heat food to their liking, and no residents experienced any issues with food temperatures. Interviews with the Administrator at 11:45 a.m. and Staff #1 (S1) at 12:05 p.m. today revealed the facility maintains a temperature log for all prepared food. The facility uses a heating lamp, hotel trays, and heated plates to store and prepare meals. LPA observed the temperature log, plate warmer, hotel trays, and heating station during the physical plant tour at 12:00 p.m. today. Based on interviews and observations, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2