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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610025
Report Date: 01/13/2025
Date Signed: 01/13/2025 01:49:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
01/06/2025 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250106161520
FACILITY NAME:PACIFICA SENIOR LIVING NORTHRIDGEFACILITY NUMBER:
197610025
ADMINISTRATOR:IVY MITCHELL SHARPFACILITY TYPE:
740
ADDRESS:8700 LINDLEY AVENUETELEPHONE:
(818) 886-5181
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:110CENSUS: 77DATE:
01/13/2025
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Resident Care Director, Francis NorberteTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Licensee not ensuring facility has an administrator on the premises a sufficient number of hours
INVESTIGATION FINDINGS:
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On 01/13/25, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Resident Care Director, Francis Norberte. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint.

The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 9:50am, LPA toured the physical plant. During the tour, LPA interviewed residents and staff.

9099C-continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
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
Control Number 31-AS-20250106161520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING NORTHRIDGE
FACILITY NUMBER: 197610025
VISIT DATE: 01/13/2025
NARRATIVE
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Regarding the allegation: Licensee not ensuring facility has an administrator on the premises a sufficient number of hours. It is being alleged that an administrator has not been on site. During LPA's physical tour, LPA asked for the administrator on site and LPA was informed by Staff #1 (S1) that there has not been administrator since December 2024. LPA asked S1 who has been covering or doing administrator duties and S1 stated several people have been doing different administrator duties at the above facility. LPA continued their physical tour and interviewed five (5) additional staff who confirmed that there has been no administrator at the above facility. LPA interviewed seven (7) residents who confirmed that there has been no administrator at the above facility since December 2024. Therefore, based on the LPA's observations, staff, and resident interviews the above allegation(s) is SUBSTANTIATED at this time.

An exit interview was conducted, a citation(s) was issued for the above allegation(s), appeal rights and a copy of this report was given to the Resident Care Director.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250106161520
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2025
Section Cited
CCR
87405(a)
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87405Administrator - Qualifications and Duties(a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met by:
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The Licensee shall hire or designate an administrator by POC:01/27/25 and send all paperwork to Community Care Licensening Department/LPA Saucedo.
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Based on the observation and staff/resident interviews the licensee did not ensure an administrator to be at the above facility for sufficient number of hours to permit adequate attention to the management and administration of the facility which poses a potential Health, Safety or Personal Rights risks to person 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC9099 (FAS) - (06/04)
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