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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610025
Report Date: 08/18/2021
Date Signed: 08/18/2021 12:07:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 NORTHRIDGEFACILITY NUMBER:
197610025
ADMINISTRATOR:VILLASENOR, LISAFACILITY TYPE:
740
ADDRESS:8700 LINDLEY AVENUETELEPHONE:
(818) 886-5181
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:110CENSUS: DATE:
08/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lisa Villasenor - AdministratorTIME COMPLETED:
12:20 PM
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At 9:15 a.m. Licensing Program Analysts (LPAs) Melissa Ruiz and Angela Panushkina conducted an unannounced Case Management-Incident visit. The purpose of this visit was to respond to a report submitted to the Woodland Hills South Regional Office on August 9, 2021. The report stated that on 08/07/2021, a staff member (S1) hurt a resident (R1). LPA met with Administrator Lisa Villasenor and stated the purpose of this visit. LPAs conducted a physical plant tour at 10:00 am and no health and safety issues were noted.

During this visit LPAs conducted interviews from 9:30 am to 11:20 am with the Administrator, five (5) staff members and one resident (R1). LPAs attempted to interview more residents but were unable to do so due to lunch time. Record review was conducted by LPAs and relevant documentation was obtained including a police investigation statement.

At this time, further investigation of the incident is needed. Exit interview conducted. Report will be emailed to Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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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