197610025-9-19-2021-31-AS-NMAN-C7HUPF-20211005154527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610025
Report Date: 09/19/2021
Date Signed: 09/19/2021 05:11:38 PM

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
03/02/2021 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20210302141649

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: 81	DATE:	09/19/2021
		UNANNOUNCED	TIME BEGAN:	03:17 PM
MET WITH:	Francis Norberte, Memory Care Director		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to provide healthful and comfortable accommodations for residents.

CCL not notified of construction.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a subsequent complaint investigation for the allegations listed above, LPA met with Francis Norberte, Memory Care Director. The purpose of the visit was discussed.

It was reported that facility failed to provide healthful and comfortable accommodations for residents. During this investigation, on 03/08/2021 at 4:25pm, LPA spoke to staff that had knowledge of the construction being done to the front floor entrance. Staff indicated that when construction began that residents were being isolated in their rooms, due to COVID-19 outbreak at the facility. As a result, residents were not entering or exiting through the front entrance. Non-essential workers and residents' families were not being allowed to enter the facility as well. On 03/08/2021, LPA did not observe any residents walking around the hallways or in the front entrance. Based on interview, observation, and record review, there is no relevant information to support this allegation. Thus, the allegation is UNSUBSTANTIATED at this time.
See 9099-A to continue

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (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 3

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
03/02/2021 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20210302141649

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: 81	DATE:	09/19/2021
		UNANNOUNCED	TIME BEGAN:	03:17 PM
MET WITH:	Francis Norberte, Memory Care Director		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

CCL not notified of construction.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a subsequent complaint investigation for the allegations listed above, LPA met with Francis Norberte, Memory Care Director. The purpose of the visit was discussed.

It was reported that Community Care Licensing Department (CCLD) was not notified of construction. To investigate this allegation, LPA Valenzuela interviewed the Executive Director (ED) and other staff on 03/08/2021 at 4:30pm. Interviews verified that no notification was sent to CCLD prior to starting construction at the facility. On 03/12/2021, during the initial complaint visit the construction was still in progress and LPA Valenzuela requested a written information report explaining when the construction will be completed and what areas are being affected. On 03/12/2021 at 8:30am, LPA Valenzuela received and reviewed the document that was sent by ED which supported the information revealed from interviews. Based on inspection, interviews, and record review, it was confirmed that the construction in the facility was initiated without prior notification to the Licensing Department. Thus the allegation is SUBSTANTIATED. Citation issued and POC cleared. Exit interview conducted and a copy of the report was issued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (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: 2 of 3

Control Number 31-AS-20210302141649

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 B 09/19/2021 Section Cited CCR 87307(d)(3)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (3) All persons shall be protected against hazards within the facility. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	POC cleared on this visit. Administrator sent letter to CCLD about the construction which as been completed.
	8 9 10 11 12 13 14	The Licensee/Administrator failed to notify CCLD of the construction that was to be done and how residents were going to be protected against hazards within the facility. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (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)

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