197610025-10-17-2023-31-AS-NMAN-CWSTF8-20231020144106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610025
Report Date: 10/17/2023
Date Signed: 10/17/2023 12:01:23 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
08/17/2022 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220817122111

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: 88	DATE:	10/17/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:			TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained pressure injury while in care

INVESTIGATION FINDINGS:

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At 10:20am on 10/17/2023, Licensing Program Analyst (LPA) Antonia Alvizar conducted a subsequent complaint visit. LPA met with Concierge, Raquel Maristela and later Memory Care Director, Frances Norberte joined and disclosed the reason for the visit.

At 10:40am LPA and Lead Caregive, Patricia Repunte conducted a physical plant walk-through and did not observe any immediate health and safety issues. On 08/24/22 Licensing Program Analyst (LPA) Joscelyn Martinez initiated complaint investigation. At 11:50am LPA conducted interviews with staff and resident. LPA obtained SCAN Health Care notes, resident, staff roster and other pertaining documents to the allegation. LPA Martinez was informed that R1 is under the specific medical program and medical professionals are attending residents in the facility. Staff revealed that R1’s had a skin tear on coccyx area as per nurse practitioner the pressure injury was at Stage 2.

Continue on LIC9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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-20220817122111

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: 10/17/2023

NARRATIVE

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Nurse practitioner was providing wound care. Staff was changing wound dressing, turning and repositioning resident every 2 hours.

On 09/19/23 LPAs Antonia Alvizar and Gina Saucedo arrived at the facility to continue investigation of the above noted allegation. At 1:20pm LPA Alvizar requested copies of the facility resident and staff roster. LPA’s conducted a physical plant walk-through, at approximately 1:45pm and did not observe any immediate health and safety issues. Between 2:00pm – 2:20pm ED, Memory Care Director and other staff were interviewed.

Interviews revealed that currently R1 does not have pressure injury. In the past in August 2022, R1 had a skin tear and was treated by a nurse practitioner from SCAN Health Care. LPAs attempt to interview R1 but unsuccessful because R1 is nonverbal. A review of R1’s medical records conducted on 10/16/23 at 3:30pm, verified the information revealed from the staff.

Based on interviews and record review, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview was conducted and a copy of report was issued to Memory Care Director, Frances Norberte.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC9099 (FAS) - (06/04)

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