425802116-5-6-2024-29-AS-KBUY-D5GTXZ-20240521150800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 05/06/2024
Date Signed: 05/06/2024 01:25:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/23/2023 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20230623160720

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: 14	DATE:	05/06/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Cynthia Garcia		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident sustained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Cynthia Garcia and explained the purpose of the visit.
During the investigation, LPA Olson conducted the initial visit on 6/29/23, and interviewed staff and residents from 2:20pm to 4:45pm. LPA also obtained relevant documentation.
On the allegation: Resident sustained injury while in care. It was alleged that on 6/20/2023, Resident 1 (R1) was observed to have bruises on their hand/arm. It was alleged that staff indicated R1 sustained the injury while being “violent” towards staff. It was also alleged that the Administrator at the time indicated the injury was the result of a fall.
Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

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-20230623160720

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING SANTA BARBARA	FACILITY NUMBER: 425802116
	VISIT DATE: 05/06/2024

NARRATIVE

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LPA interviewed R1, who indicated that they received the bruise from falling and both their hands hit their chest. R1 indicated staff helped them and had never hurt them. R1 indicated they liked the facility and received “great care.” R1 also stated they had a scratch from a tiger on their hand.

LPA interviewed staff, who indicated R1 sometimes has aggressive behaviors due to their dementia diagnosis. Multiple staff indicated R1 has sustained bruises on their arm from hitting it on doors or gates.

LPA reviewed documents including an internal incident report dated 6/19/2023 at 11:30am-12pm. The report states R1 was agitated pushing another resident’s wheelchair and became aggressive when staff intervened, trying to punch and push them. According to the documentation, R1 sustained a skin tear on their right hand. LPA observed photos of the resident’s skin tear from 6/23/24, which appeared to also have bruising. The documentation also indicates the incident and skin tear were reported to their doctor and responsible party.

Based on the evidence obtained, there was insufficient evidence to prove R1 sustained an injury as a result of staff neglect or abuse. Therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024

LIC9099 (FAS) - (06/04)

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