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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 07/30/2021
Date Signed: 07/30/2021 03:41:06 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2019 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20191028162628
FACILITY NAME:PACIFICA SENIOR LIVING SANTA BARBARAFACILITY NUMBER:
425802116
ADMINISTRATOR:PENNINGTON, KATRINAFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 898-2650
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 16DATE:
07/30/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Mary Moore, Administrator, and Miriam Santiago, Business Office ManagerTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Licensee failed to keep the facility free of rodents and/or insects.

INVESTIGATION FINDINGS:
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On 7/30/2021 at 1:25 pm, Licensing Program Analyst (LPA) Chavez initiated a complaint visit to discuss the final findings for the allegation listed above. LPA met with Mary Moore, Administrator, and Miriam Santiago, Business Office Manager, and informed of the reason for the visit.

On the allegation “Licensee failed to keep the facility free of rodents and/or insects”, the complainant’s concern was that the facility has five (5) birds in a cage in the common area which is not cleaned regularly and attracts flies. To investigate the allegation, LPAs Kontilis and Chavez toured the facility.

Continued on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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 6
Control Number 29-AS-20191028162628
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING SANTA BARBARA
FACILITY NUMBER: 425802116
VISIT DATE: 07/30/2021
NARRATIVE
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On 11/04/19, LPA Kontilis observed a bird cage containing five (5) doves in the outside area between the administrator’s office and the main building. LPA observed the cage to contain bird feces and fruit in and around the cage with several flies and ants surrounding the cage. LPA found that the birds flutter around and food from their cage gets thrown to the ground outside the cage where ants were seen. LPA also observed bird feces in and around the cage with flies surrounding the cage. Based on the information obtained, the allegation that, “Licensee failed to keep the facility free of rodents and/or insects.” is Substantiated.

Exit interview conducted, deficiency cited, and a copy of the report emailed to administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20191028162628
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING SANTA BARBARA
FACILITY NUMBER: 425802116
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2021
Section Cited
HSC
87303(f)1)
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87303 - Maintenance and Operation
Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. This requirement was not met as evidenced by:
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The administrator has instructed staff to take greater measures to clean the inside and area outside the bird cage to reduce feces and excess food and keep the facility free of insects and flies. Specifically, there are designated staff to clean the cage and surrounding area twice per week. This measure has already been completed.
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Based on observations, the licensee did not ensure that sufficient measures were taken to keep the area in and around the bird cage free from flies and ants. This poses a potential health risk to all clients 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2019 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20191028162628

FACILITY NAME:PACIFICA SENIOR LIVING SANTA BARBARAFACILITY NUMBER:
425802116
ADMINISTRATOR:PENNINGTON, KATRINAFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 898-2650
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 16DATE:
07/30/2021
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Mary Moore, Administrator, and Miriam Santiago, Business Office ManagerTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff failed to ensure there is an adequate amount of personal hygiene supplies.to meet the residents' needs.
Licensee failed to ensure residents are accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
The facility has an insufficient amount of staff to meet the residents' needs.
INVESTIGATION FINDINGS:
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On 7/30/2021 at 1:25 pm, Licensing Program Analyst (LPA) Chavez initiated a complaint visit to discuss the final findings for the allegations listed above. LPA met with Mary Moore, Administrator, and Miriam Santiago, Business Office Manager, and informed of the reason for the visit.

On the allegation “Facility staff failed to ensure there is an adequate amount of personal hygiene supplies.to meet the residents' needs”, the complainant’s concern was that the facility does not have large diapers for residents needing XL or XXL. To investigate the allegation, LPAs Kontilis and Chavez interviewed staff, toured the facility, reviewed facility records, and attempted to interview residents.

Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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 6
Control Number 29-AS-20191028162628
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING SANTA BARBARA
FACILITY NUMBER: 425802116
VISIT DATE: 07/30/2021
NARRATIVE
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On 11/04/19, LPA Kontilis toured the facility and observed a large supply of personal hygiene supplies in a variety of sizes. Items were stored in two different storage areas accessible to staff. On 7/27/21, LPA Chavez toured the facility and observed a closet in the medication room containing over thirty (30) packages of diapers in a variety of sizes. Business Office Manager stated that they also keep a back-up supply in her office and incontinent supplies are available in resident rooms. LPA reviewed invoices for incontinent supplies purchased in September and October 2019. Facility purchased a sufficient amount of incontinent products in a variety of sizes to provide for resident needs. Based on the information obtained, the allegation that, “Facility staff failed to ensure there is an adequate amount of personal hygiene supplies to meet the residents' needs.” is Unsubstantiated.

On the allegation “Licensee failed to ensure residents are accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.”, the complainant’s concern was that staff is cleaning the resident rooms while they sleep and this exposes residents to cleaning chemicals. Further concerns are that residents are waking during cleaning due to the chemical smell. To investigate the allegation, LPA Chavez interviewed staff and toured the facility, and attempted to interview residents.

On 7/21/21, administrator emailed LPA with a housekeeping schedule showing the days of the week and shifts within a day, areas in the facility to be cleaned, and laundry days. At 4:32 pm, LPA spoke with administrator who stated that the facility does not keep a housekeeping log to record the staff who performed the duties, and the date, time, and location of cleaning and laundry, however, she stated that staff do not clean resident rooms while they are present. On 7/29/21, LPA Chavez interviewed staff who stated the NOC shift cleans common areas such as the hallways and dining room by mopping the floors, cleaning scuffs on the walls, disinfecting showers located outside resident rooms, and washing windows. Staff interviewed stated that NOC shift personnel “do not clean resident rooms unless the residents are already awake after breakfast.” Based on the information obtained, the allegation that, “Licensee failed to ensure residents are accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.” is Unsubstantiated.

Continued on 9099C.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20191028162628
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING SANTA BARBARA
FACILITY NUMBER: 425802116
VISIT DATE: 07/30/2021
NARRATIVE
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On the allegation “The facility has an insufficient amount of staff to meet the residents' needs”, the complainant’s concern was that the facility is not adequately staffed to meet the resident’s needs. Complainant stated the facility often has only one or two staff members to assist the seventeen (17) residents at the facility who have dementia. Complainant was concerned that four (4) of the residents require a two-person transfer and may not be transferred in a timely manner, if staff is busy with other residents. To investigate the allegation, LPA interviewed staff and reviewed facility records, and attempted to interview residents. LPA reviewed staffing records and observed three (3) staff worked on the AM shift, three (3) staff worked on the PM shift, and two (2) staff worked on the overnight shift.

On 7/27/21 and 7/29/21, LPA Chavez interviewed staff. Staff reported that they believe there is enough staff to meet resident needs. they stated six (6) residents who needed a two-person assist were on hospice, and hospice aides assisted during the week. LPA asked staff if they ever thought there wasn’t enough staff on weekends, and staff interviewed stated they did not. They stated “I wouldn’t work at a place that was short-staffed.” Staff stated they were not required to work double shifts. They further mentioned that when a staff called out sick, the Business Office Manager and Activities Director would assist with residents’ needs. Based on the information obtained, the allegation that, “The facility has an insufficient amount of staff to meet the residents’ needs.” is Unsubstantiated.

Exit interview conducted, and a copy of the report emailed to administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6