197610025-10-2-2023-31-AS-NMAN-CWNSYU-20231016141805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610025
Report Date: 10/02/2023
Date Signed: 10/02/2023 03:56:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
07/21/2022 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20220721122026

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: 89	DATE:	10/02/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Lisa Villasenor		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff yells at resident

INVESTIGATION FINDINGS:

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At 9:35 a.m. on 10/02/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced, subsequent complaint visit. LPA met with staff and later the Administrator and disclosed the reason for the visit.

To investigate the allegation above, LPA toured the physical plant at 9:45 a.m. and 12:00 p.m. today, reviewed the staff list and resident list at 10:00 a.m., and interviewed 10% of staff and 10% of residents between 10:10 a.m. and 12:30 p.m.

Regarding the allegation “Staff yells at resident” it was alleged that Staff #1 (S1) yells at residents who refuse medication. Review of the staff list at 10:00 a.m. today revealed S1 was not a current employee. Interview with the Administrator at 11:45 a.m. today revealed S1 was fired approximately 4 months ago due to an incident between staff members, though S1 never yelled at residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

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-20220721122026

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING NORTHRIDGE	FACILITY NUMBER: 197610025
	VISIT DATE: 10/02/2023

NARRATIVE

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The Administrator further stated medications are provided in the dining room, so staff observe one another when medications are provided. Staff know to report any incidents of abuse. Interview with Staff #2 (S2) and Staff #3 (S3) at 12:20 p.m. and 12:30 p.m. today revealed no staff had been observed yelling at residents. Resident interviews between 10:10 a.m. and 11:25 a.m. today revealed they had never been yelled at by a staff member. Based on interviews and observations, there is insufficient evidence to verify the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023

LIC9099 (FAS) - (06/04)

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