425802116-2-21-2023-29-AS-KKOS-CPA5JV-20230221190034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 02/21/2023
Date Signed: 02/21/2023 07:01:36 PM

Document Has Been Signed on 02/21/2023 07:01 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 BARBARA		FACILITY NUMBER:	425802116
ADMINISTRATOR:	MIRIAM SANTIAGO		FACILITY TYPE:	740
ADDRESS:	325 W ISLAY ST		TELEPHONE:	(805) 898-2650
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	36	CENSUS: 18	DATE:	02/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:53 PM
MET WITH:	Miriam Santiago, Administrator		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 1:53 pm and was greeted by Administrator Miriam Santiago. LPA explained the purpose of the visit. Entrance interview conducted. The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a hospice waiver for 18. Currently, there are 18 residents with a dementia diagnosis and 3 residents on hospice. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the facility for personal accommodations, food service, and fire safety. The facility has 3 fire extinguishers serviced on 1/5/2023; 5 fire pull alarms, and a sprinkler system. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility maintains a comfortable temperature. The kitchen is equipped with industrial kitchen equipment and is kept neat and clean. There is a sufficient amount of perishables for two-days and non-perishables for seven days. Medications and First Aid kits are kept in the locked Nurse’s station. Residents’ records and personnel records are kept in a locked closet in the hallway. Only the Administrator can access the records. Residents participate independently in live entertainment and music, worship support, exercise activities, card games, Bingo, and scenic drives. If any suspected or confirmed cases of COVID-19 are found in the facility a staff will be assigned to only work with those quarantined/isolated individuals and will not work with other COVID-19 negative individuals until cleared by Health Department. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of COVID-19. Precautionary Droplet signs will be posted on any room with quarantine or isolated individuals. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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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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
	VISIT DATE: 02/21/2023

NARRATIVE

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PPE supplies will be located immediately outside those rooms when required. Facility has a 30-day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined/isolation resident room.
The facility has proper cleaning and disinfectant sprays. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results.
Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Staff who have a respiratory illness are requested to stay home and not report to work.
Activities have been modified to individuals or small groups with social distancing. Residents' medication is delivered in 30-day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items.
Sinks were well stocked with soap, paper towels and hand washing signs. Staff and resident records are kept in the locked Nurse's station. Facility observes guidance changes and the most up-to-date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies.
At approximately 2:14 pm, LPA observed Staff 1 with no face covering at the time of inspection. LPA requested S1 to put on a face covering and wear it in the facility at all times. S1 agreed to do so.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalties assessed.

Exit interview conducted. A copy of this report, Appeal Rights, and Civil Penalty issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/21/2023 07:01 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: 02/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87368.1

87468.1 Personal Rights: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the facility failed to ensure Staff 1 (S1) was wearing a face covering correctly which poses an immediate health, safety and personal rights risk to residents in care.
	POC Due Date: 02/23/2023
	Plan of Correction
1 2 3 4	Administrator agrees to conduct an infectious control training, review and train staff on all recent PIN’s released for 2022 and 2023, including mask-wearing mandates, and provide copy of training and staff signatures to CCL by 2/23/2022. Signatures to include first and last name.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC809 (FAS) - (06/04)

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