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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610025
Report Date: 09/19/2021
Date Signed: 09/20/2021 08:35:27 AM



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
12/16/2020 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20201216115023
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: 81DATE:
09/19/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Francis Norberte, Memory Care DirectorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Facility did not provide timely medical attention

Staff yells on the other staff in front of residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannouced complaint visit to the facility. LPA met with Francis Norberte, Memory Care Director and explained the purpose of the visit. Investigation of the above noted allegations was initiated by LPA Naira Margaryan.

It was reported that on 11/25/2020 in the morning that Resident #1 (R1) was having a hard time breathing and that no medical attention was provided to R1 To investigate this allegation on 12/17/2020 at 11:20am, LPA Margaryan spoke with the ED and she verified that on 11/25/2020 R1 was pale and weak. However, the facility nurses checked on R1 and found no reason to call an ambulance. On 12/17/2020 between 2:00pm and 4:00pm LPA spoke to caregivers who assisted R1 on 11/25/2020. Interviews revealed that on 11/25/2020 between 4:30pm and 9:30pm, staff #1 (S1) noticed black fluid coming out from R1's mouth. Within 5 hours, R1 was checked three (03) times and observed to be weak and had irregular breathing. A review of R1's records conducted on 08/30/2021 at 2:00pm, revealed that R1 had a heart condition and other health issues.
See 9099-C for continuation
Substantiated
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 4
Control Number 31-AS-20201216115023
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: 197610025
VISIT DATE: 09/19/2021
NARRATIVE
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Investigation revealed that although staff observed R1 being weak and having a hard time breathing, no one contacted the doctor or called an ambulance to seek further medical evaluation. Therefore, based on interviews and record review, the allegation is SUBSTANTIATED at this time.

Under Title 22, Division 6, Chapter 8, the following deficiencies were cited and recorded on LIC 9099D.
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 4
Control Number 31-AS-20201216115023
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: 197610025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2021
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident's health including but not limited to, an apparent life-threatening medical crisis.
This requirement was not met as evidenced by :
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The Licensee/ Administrator will notify CCL in writing how they will ensure incidental care to residents in care.
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The Licensee did not ensure to provide incidental medical care to R1 who was having breathing difficulties. This poses an immediate health and safety hazard to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
12/16/2020 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20201216115023

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: 81DATE:
09/19/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Francis Norberte, Memory Care DirectorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff yells at the other staff in front of residents in care
INVESTIGATION FINDINGS:
1
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3
4
5
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint visit to the facility. LPA met with Francis Norberte, Memory Care Director an explained the purpose of the visit. Investigation of the above noted allegations was initiated by LPA Naira Margaryan.

It was reported that on 12/15/2020 that staff #1 (S1) yelled at staff #2 (S2) in front of resident #2 (R2) while S2 was asking for S1 to assess R2. During this investigation on 12/17/2020 at 11:20am, LPA spoke with other facility staff, including S1 and S2. S1 denied yelling at S2. S1 stated that on 12/15/2020 they spoke with S2 via intercom and instructed S2 to escort resident #2 to their room. Other staff denied seeing S1 yelling at S2.

Based on information revealed during the investigation, there is no sufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
Exit interview was conducted and a copy of the report was issued.
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: 4 of 4