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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:28:05 PM


Document Has Been Signed on 02/25/2022 12:28 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PACIFICA SENIOR LIVING SANTA BARBARAFACILITY NUMBER:
425802116
ADMINISTRATOR:ALLAMARY E. MOOREFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 898-2650
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 20DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Miriam SantiagoTIME COMPLETED:
12:40 PM
NARRATIVE
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On 02/25/22 at 10:00 a.m., Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrator Miriam Santiago and explained the purpose of the visit.

LPA was screened at the entrance, and LPA toured the residential care facility for the elderly. At 10:50 a.m., LPA discussed items in the Infection Control Module and noted that facility did not California Department of Social Services Provider Information Notices (CDSS PINs) available to residents. PINs were posted in the medication room. Administrator will post PINs in a location visible to residents and visitors at the bulletin board. LPA also noted that not all sinks had paper towels as residents have private rooms with their own personal towels. Administrator answered yes to all other questions in the Infection Control. Infection Control module was addressed with administrator to satisfaction. Between 11:30 a.m. and 12:00 p.m., LPA reviewed facility schedule and found 1 individual working at the facility without a Criminal Record Clearance. Individual was not present at the facility during the inspection. Administrator removed staff from the schedule. LPA issued citation under Title 22, Division 6 Chapter 8 Article 06. Background Check 87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.

Deficiency issued on LIC 809D. A civil penalty was issued. LPA conducted exit interview with administrator and emailed a copy of today's report and appeal rights to the administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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Document Has Been Signed on 02/25/2022 12:28 PM - It Cannot Be Edited

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. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: PACIFICA SENIOR LIVING SANTA BARBARA
FACILITY NUMBER: 425802116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the LPA found one staff on the facility roster that did not have criminal record clearance. The licensee did not comply with the section cited above in 1 count which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2022
Plan of Correction
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Administrator removed staff from the schedule. Administrator gave verbal confirmation of understanding on how to obtain clearance from Community Care Licensing or have individuals complete Request for Live Scan prior to working. Adminsitrator will verify individual is cleared before working at the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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