197610025-7-28-2022-31-AS-NGID-CHBU2N-20220815151213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610025
Report Date: 07/28/2022
Date Signed: 07/28/2022 01:27:42 PM

Unsubstantiated

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
07/14/2022 and conducted by Evaluator Joscelyn Martinez

COMPLAINT CONTROL NUMBER: 31-AS-20220714110418

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: 83	DATE:	07/28/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Lisa Villasenor		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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No hot water in the laundry
Bugs in resident rooms
No air conditiong in med tech room
Resident food is served cold

INVESTIGATION FINDINGS:

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On 07/28/22 Licensing Program Analyst (LPA) Joscelyn Martinez conducted a subsequent complaint visit. LPA conducted a 10-day visit for these allegations on 07/20/22 due to the need of more information LPA needed further investigationat the time. Upon arrival LPA met with Administrator Lisa Villasenor and the purpose of the visit was explained.

Allegation:1 No hot water in the laundry
It is alleged that there is not hot water in the laundry area. According to interviews and documentation, on 07/07/22 there was a small break in the water valve that affected the water in the laundry area. Administrator contacted a third-party vendor to come into the facility and correct the issue. Third party invoice stated that there was no hot water and the vendor was able to correct the issue the same day. Due to the incident being corrected the same day, this allegation is deemed Unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

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-20220714110418

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: 07/28/2022

NARRATIVE

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Allegation 2: Bugs in resident rooms

It is alleged that there are water bugs in the facility. LPA conducted interview with residents and staff. Two (2) out of ten (10) residents stated they have seen water bugs in the bathtub. Three (3) out of six (6) staff have seen water bugs in the facility. According to paperwork obtained, facility has monthly fumigations by a third-party vendor. According to the administrator when a staff reports a sighting of a water bug facility will contact fumigation services for additional services. According to administrator these water bugs mostly live outside but do have access to the plumbing which is how they might end up in the resident’s bathtub. During the time of the physical walk through conducted on 07/20/2022 and 07/28/22 LPA did not observe any water bugs or other types of pest in the facility. Furthermore, LPA contacted the third-party vendor that the facility uses to fumigate. LPA was able to speak with the owner and stated that the facility does not have an infestation and it common for water bugs to come up the plumbing into the facility. These sightings of water bugs are prevalent during the summer months.

Allegation 3: No air conditioning in med-tech room

It is alleged the air conditioner is broken inside the med-tech room. Interview conducted revealed that residents do not enter the medication room therefore it is not a Title 22 requirement. LPA did observe multiple fans inside the room for staff. Due to this allegation not being a requirement under Title 22 this allegation is deemed Unsubstantiated.

Allegation 4: Resident food is served cold

It is alleged that resident’s food is being served cold. LPA conducted interviews with staff and one (1) out of ten (10) residents stated that the food is being served cold. Interview with the Dinning Service Director and Administrator revealed that the steam table was not functioning properly for a short period of time. During this time staff found alternative ways to keep the food warmer for a longer period of time but staff stated they would not serve residents food that was cold. Steam tables were fixed on the July 16th 2022 and are now functional. Due to the information gathered this allegation is deemed Unsubstantiated

No deficiencies cited .Exit interview conducted. Report signed and delivered. Appeal rights issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022

LIC9099 (FAS) - (06/04)

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