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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 12/14/2022
Date Signed: 12/30/2022 07:54:43 AM


Document Has Been Signed on 12/30/2022 07:54 AM - 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:MIRIAM SANTIAGOFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 898-2650
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 18DATE:
12/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Miriam Santiago, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Case Management – Incident visit to the above-named facility. LPA arrived at approximately 3:35 pm. LPA met with Miriam Santiago, Administrator and explained the purpose of the visit.
Entrance interview conducted:
On 11/28/2022, Miriam Santiago, Administrator, reported to CCL approximately twenty-one (21) new COVID-19 positive cases via a telephone call directly to CCLD’s Goleta Regional Office. LPA Olson obtained the COVID positive informational call per CCLD’s COVID protocol. On 11/28/2022, LPA Olson advised Administrator Santiago that all new COVID positive cases need to be submitted in writing within seven (7) days of the occurrence.
Based on record review, serious illness/injury reports have not been submitted to CCLD on twenty-one COVID-19 cases reported on 11/28/2022.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted. Civil penalty assessed. Copy of report and Appeal Rights issued via email.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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 12/30/2022 07:54 AM - 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: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited

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87211(a)(1)(D) Reporting Requirements: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in...(D) Any incident which threatens the welfare, safety or health of any resident.
This requirement not met as evidenced by:
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Administrator agrees to submit serious illness/injury reports to CCL of all residents/staff who tested positive with COVID-19 no later than 12/19/2022.
Administrator agrees to submit detailed written statement acknowledging intention to comply with CCR 87211 to LPA via email.
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Based on record review, the licensee did not comply with the section cited above as 21 out of 21 serious injury/incident reports were not received by CCL within 7 days of their occurrence on 11/26/2022 which poses a potential health & safety risk to residents 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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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