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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 02/21/2023
Date Signed: 02/21/2023 07:03:31 PM


Document Has Been Signed on 02/21/2023 07:03 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:MIRIAM SANTIAGOFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 898-2650
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 18DATE:
02/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:53 PM
MET WITH:Miriam Santiago, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit to address deficiencies noted during a tequired Annual Infection Control Inspection visit conducted on 2/21/2023. LPA met with Miriam Santiago, Administrator and explained the purpose of the visit.

Upon record review and interviews conducted, LPA determined no hospice notifications have been received by CCL since 6/18/2021. Further, upon record review and interviews conducted, no death reports have been received by CCL since 9/15/2021.

The facility has a hospice care waiver of 18. LPA counseled Administrator Santiago on the importance of following the requirements in California Code of Regulations (CCR) 87632 Hospice Care Waiver. LPA recommended Administrator Santiago review CCR 87632 in its entirety to determine if the facility can adhere to the CCR hospice care waiver requirements.

Administrator stated some residents on hospice have been transferred to another facility by the suggestion of a hospice care agency with residents’ responsible parties.

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

Exit interview conducted. Deficiencies cited. Copy of report and Appeal Rights issued.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (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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Document Has Been Signed on 02/21/2023 07:03 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2023
Section Cited

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87632(d)(2) Hospice Waiver: The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services.
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Administrator agrees to conduct training with all staff responsible for submitting hospice notification. Training records will show full names of attendees, date of training, and person conducting training with first and last names in print and signature.
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This requirement is not met as evidenced by:
Based on records review, the licensee did not comply with the section cited above as CCL has not received hospice notifications for residents placed on hospice since 6/18/2021 which poses an immediate health and safety risk to residents in care.
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Type A
02/23/2023
Section Cited

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87211(a)(1)(A) Reporting Requirements:... Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
This requirement is not met as evidenced by:
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Administrator agrees to conduct training with all staff responsible for submitting death reports to CCLD. Training records will show full names of attendees, date of training, and person conducting training in print and signature.
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Based on records review, the licensee did not comply with the section cited above as CCL has not received notifications of residents’ death since 9/11/2021 which poses an immediate health and 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: 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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