197610025-3-10-2024-31-AS-GSAO-D38RQA-20240310131314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610025
Report Date: 03/10/2024
Date Signed: 03/10/2024 01:13:41 PM

Document Has Been Signed on 03/10/2024 01:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

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: 86	DATE:	03/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:50 AM
MET WITH:	Francis Norberte		TIME COMPLETED:	01:25 PM

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On 03/10/24 at 7:55AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Resident Care Director Frances Norbete and disclosed the purpose of the visit. Lisa Villasenor, the administrator was called and arrived about an hour and half later.

LPA asked for the census, resident, and staff rosters.

A physical tour was conducted at 9:35 AM and observed the following:

The entire facility has a total of 110 (one-hundred and ten) beds. Forty-three (43) are currently in the memory care unit. All the rooms are on the second floor. The floor is divided by assisted living and memory care. The assisted living is on your left-hand side of the facility and the memory care is on your right-hand side of the facility. The second floor consists of a medication room which is in the memory care section. The memory care section has their own activity and dining hall. There is also a delayed egress on the doors. The assisted living side has their own activity room. The assisted living side has access to the ground level which is the first floor which has the laundry room area, beauty salon, dining hall, access to the patio area and another activity room area.

Random Bedrooms were randomly selected to tour and were observed to have appropriate furniture, lightening, bedding, and televisions. Random Bathrooms were observed to have grab bars and non-skid mats. Hot water temperature was tested randomly for and measured 115–118-degree Fahrenheit.

There is one facility laundry area on the first level with chemicals inaccessible to the residents.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING NORTHRIDGE	FACILITY NUMBER: 197610025
	VISIT DATE: 03/10/2024

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Fire extinguishers were observed throughout the facility and were fully charged on green with different dates. There are fire extinguishers upstairs, downstairs and in the kitchen area. Carbon Monoxide and fire alarms are located throughout the facility and are operable.

Facility has a designated medication room that is inaccessible to residents where all the medication is stored and locked in the memory care side of the facility. There are always two (2) med-tech staff in there during the daytime for each side-memory care and assisted living. Medication was revised randomly.

The assisted living area: outside/backyard is accessible to residents with different areas for them to sit. There is appropriate outdoor furniture for the residents to sit on with proper shading. There is no body of water.

Common Areas: These include the dining areas, beauty salon, and activities room. All common areas were observed to be cleaned and properly furnished. The activity room has a large television and has enough seating for several residents to watch the television and do different activities. Facility maintains a comfortable temperature of 69.-72-degree Fahrenheit. There are several temperature thermostats throughout the facility. There are several common bathrooms throughout the upstairs and downstairs area. The staff and resident bathrooms are not shared. There are trash cans with lids and covid signs posted in the common bathrooms. There is toilet paper and napkins.

The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The dining area is located next to the kitchen where different residents were having breakfast with proper feeding utensils/plates/cups.

Administrative: There is no annual fee that is due right now. The Insurance plan is dated as of 09/2023. There is a disaster plan, licensee certificate, designee and Infection control binder. The last fire drill conducted was on 02-12-2024.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2024

LIC809 (FAS) - (06/04)

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