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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610025
Report Date: 08/29/2022
Date Signed: 08/29/2022 12:43:16 PM


Document Has Been Signed on 08/29/2022 12:43 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
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: 88DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lisa Villasenor TIME COMPLETED:
12:50 PM
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On 08/29/22 at 11:00 a.m Licesing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an announced annual inspection. Upon arrival LPA met with Administrator Lisa Villasenor and the purpose of the visit was explained. LPA toured the facility with designee Francis Norberte. The following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPA’s temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Staff were observed wearing proper face masks. Food Inspection: Kitchen and dining area are located on the ground floor of the facility. LPA Martinez observed there was sufficient stock of one-week non-perishable foods and two-day perishable foods. Kitchen was observed to be sanitary and free of pests. Smoke detectors/carbon monoxide are hardwired and located throughout the facility. Fire alarms are program to dispatch the fire department therefore LPA obtained paperwork for the last fire alarm inspection which was conducted on 12/07/21. Fire extinguishers were observed to be charged with a service date of 06/17/2022. Common Areas: Common areas consists of front lobby sitting area, activities room in assistance living, and two activities room in memory care. All areas were properly furnished. and sanitary with sufficient room for residents to lounge. Facility also has a beauty salon located on the ground floor. LPA observed residents in the room receiving services. Laundry area is located on the ground floor of the facility. Facility has one med-tech room that is located inside memory care. This room is kept inaccessible to residents. Resident Rooms: Facility consists of 82 rooms. Rooms consists of single or shared occupancy. A random selection of bedrooms were toured both in memory care and assisted living. All bedrooms were properly furnished and had appropriate bed linens. Rooms were observed to be sanitary. Bathrooms: Bathrooms were toured and observed to be clean and properly stocked with towels and soap. Hot water was tested and measured between 107.1-115.1 degrees F. Nonskid mats and grab bars were observed in all bathrooms.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING NORTHRIDGE
FACILITY NUMBER: 197610025
VISIT DATE: 08/29/2022
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Outside: LPA toured the outside area of the facility. LPA observed two private patios located in memory care with appropriate outside furniture and shaded area for residents. During the time of the inspection, LPA observed activities being conducted with memory care residents in the outside patios. LPA also observed a shaded covered patio with appropriate furniture for assisted living residents.

No deficiencies cited. Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022
LIC809 (FAS) - (06/04)
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