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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 12/18/2023
Date Signed: 12/18/2023 04:43:08 PM


Document Has Been Signed on 12/18/2023 04:43 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:KAREN DACOMEFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 898-2650
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 14DATE:
12/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Cynthia Garcia, Business Office ManagerTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to follow up on an immediate exclusion order issued 11/16/2023 for Staff 1 (S1). Marco Quintanar, Program Manager, Long Term Care Ombudsman (LTCO), Santa Barbara County accompanied LPA in the visit. LPA and LTCO met with Allie Sotelo, Medication Technician and explained the purpose of the visit. Cynthia Garcia, Business Office Manager arrived at approximately 11:43 am. Prior to assistance, Business Office Manager completed the process to associate self to the facility.

At approximately 8:17 am, LPA reviewed the facility’s fingerprint clearance roster and observed S1 was still associated to this facility. Cynthia Garcia, Business Office Manager disassociated S1 from their fingerprint roster during the visit.

Regional Director of Operations Tierre Thornton stated S1 had not been physically present in the facility since 12/6/2023, the date when Tierre Thorton stated the exclusion order was received. LPA interviewed other staff in the facility who confirmed S1 had not been present recently. LPA reminded Garcia that any further presence of S1 in the facility or interacting with clients violates the exclusion order and the facility could be subject to deficiencies and civil penalties if they do not abide by the order.

Exit interview conducted. Copy of report issued at the time of the visit.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
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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