425802116-6-13-2023-29-AS-KBUY-CWHW47-20231011165705

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 06/13/2023
Date Signed: 06/13/2023 02:31:16 PM

Substantiated

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
06/13/2023 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20230613091004

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: 19	DATE:	06/13/2023
		UNANNOUNCED	TIME BEGAN:	01:14 PM
MET WITH:	Miriam Santiago		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility staff did not issue a timely refund in the event of a resident’s death.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced initial complaint visit for the above stated allegation. LPA met with Administrator Miriam Santiago and explained the purpose of the visit.
Entrance interview conducted:
On the allegation, Facility staff did not issue a timely refund in the event of a resident’s death: Resident 1 (R1) passed away on 4/27/2023 while residing in the facility. R1’s belongings were removed by R1’s family members on the day of R1’s passing (4/27/2023). On or about 4/29/2023, R1’s Responsible Party (RP) received a telephone call from Administrator Miriam Santiago stating RP would be receiving a refund for pre-paid fees for R1.
After 4/29/2023, RP did not hear from Administrator Santiago and no refund has been received by RP. On 6/12/2023, at approximately 9:30 am, RP sent an email to Administrator Santiago inquiring about the refund. To date, RP has not received a response to the email and there has been no contact or correspondence

Please continue to 9099-C, Pg 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230613091004

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: 06/13/2023

NARRATIVE

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between Administrator Santiago, Pacifica Senior Living Santa Barbara and/or Licensee, Pacific Coast Senior Living Management, LLC corporate associates.
At the time of the visit, LPA obtained documents pertaining to the allegation.
At the time of the visit, Administrator stated an accounting is still being completed by Administrator Santiago. Administrator stated there appears to be errors in R1's accounting ledger and the accounting reconciliation should be completed by 6/15/2023. Administrator stated she received an email from R1’s RP, however has not yet responded to it.
Based on interviews conducted and records reviewed, LPA determined that the Licensee should have issued a refund within fifteen (15) days after R1’s belongings were removed from the facility; therefore, the allegation that facility staff did not issue a timely refund in the event of a resident’s death is Substantiated at this time.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC9099-D).
Exit interview conducted. Citation issued. Copy of report and Appeal Rights issued at the time of the visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230613091004

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: 06/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/15/2023 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	HSC 1569.652(c) Termination of admission agreement upon death of resident…refund of fees paid…(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.	1 2 3 4 5 6 7	Administrator agrees to notify of corporate of the accounting issues and request a refund no later than 6/15/2023. Administrator agrees to request the refund be sent no later than Friday, 6/16/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as Licensee failed to provide R1’s Representative with a refund within 15 days after R1 passed away and personal belongings removed, which posed a potential health, safety, or personal rights to residents in care.	8 9 10 11 12 13 14	Administrator agrees to contact Cassandra Bradford, Regional of Operations, Pacifica Senior Living Management, LLC.
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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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC9099 (FAS) - (06/04)

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