425802116-3-10-2022-29-AS-KBUY-CCEVLP-20220311153217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:59:35 AM

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
04/27/2020 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20200427131223

FACILITY NAME:	PACIFICA SENIOR LIVING SANTA BARBARA		FACILITY NUMBER:	425802116
ADMINISTRATOR:	ONYEBUCHI, AHAOMA N		FACILITY TYPE:	740
ADDRESS:	325 W ISLAY ST		TELEPHONE:	(805) 898-2650
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	36	CENSUS: 21	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Miriam Santiago		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident assaulted other resident(s) in care
Facility is not adequately staffed to meet residents’ needs

INVESTIGATION FINDINGS:

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On 3/10/2022 at 9:20 a.m., Licensing Program Analyst (LPA) Toan Luong conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Business Office Manager Miriam Santiago acting as interim administrator and explained the reason for the visit.

On 04/27/2020, the Department received a complaint alleging “Resident assaulted other resident(s) in care” and “Facility is not adequately staffed to meet residents’ needs”.

On 05/06/2020, from 9:00am to 11:30am, LPA Kristin Kontilis initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with Mary Moore, Executive Director. At approximately 9:10am through 11:10am, LPA Kontilis conducted telephone interviews with Miriam Santiago, Business Office Manager and Mary Moore, Executive Director.
(Continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 29-AS-20200427131223

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: 03/10/2022

NARRATIVE

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LPA also requested copies of documents pertaining to the investigation. On 03/02/2022, from 2:00pm to 4:20pm, (LPA) Kontilis conducted a subsequent complaint visit to the facility and met with Miriam Santiago, Interim Administrator and Business Office Manager. LPA obtained documents pertaining to the above-stated allegations and conducted interviews from 2:00pm to 4:10pm. LPA Kontilis conducted interviews with the complainant on 05/01/2020 and 05/05/2020; with staff on 05/04/2020 at approximately 4:55pm, on 03/02/2022 at approximately 11:36am to 2:10pm, and on 03/04/2022 at approximately 11:19am.

On 04/15/2020, Resident #1 (R1) was admitted to the facility. R1’s Physician Report, signed 04/14/2020 by Dr. Winner, listed the diagnosis as AFib, HTN, hyperlipidemia, anxiety and dementia. Additional conditions included aggressive, inappropriate, wandering, sundowning behaviors, confused and disoriented. R1’s ability to communicate needs and feed self was listed as borderline.

On the allegation: Resident assaulted other resident(s) in care. On 04/25/2020, at approximately 9:45am, R1 became aggressive and began flipping over tables, chairs and planted pots in the dining room and courtyard. Staff and residents were present during the incident and reported being pushed or hit by R1’s actions. Staff called 911, and Santa Barbara City Police arrived and assessed R1. R1 exhibited increased agitation and police subdued resident handcuffed on the ground. Once R1 was calm, the med tech was able to provide R1 their prescribed PRN for anxiety. On 04/26/2020, at approximately 6:30am, R1 approached staff and requested a shower. Staff escorted R1 to the shower when R1 pushed staff. Staff moved away from R1 to give space, R1’s agitation increased and began banging on the med room window. R1 then went to the outdoor courtyard and attempted to jump over the gate. Staff was able to redirect resident back inside. Staff called 911, and Santa Barbara City Police arrived and assessed R1. On both dates, police stated they were unable to take R1 via 5150 and the facility was instructed to call the crisis hotline prior to calling 911 for 5150 situations.

On 04/27/2020, the Executive Director contacted R1’s physician to request a medication evaluation for R1 and the PRN medication order was changed to routine. Staff received an in-service training regarding the protocol for future incidents and were instructed to call crisis hotline to request paramedics instead of police officers so that the mobile crisis unit could intervene. A review of the April 2020 staff schedule and statements from management and staff interviews revealed that at the time R1 was admitted to the facility on 04/15/2020, there was not an adequate amount of staff to provide the proper care and supervision to R1. Based on the information obtained, the allegation is deemed substantiated at this time.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20200427131223

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: 03/10/2022

NARRATIVE

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On the allegation: Facility is not adequately staffed to meet residents’ needs. A review of the April 2020 resident roster found that there were thirteen (13) residents, of which six (6) were on hospice. All residents had a diagnosis of dementia. Five (5) residents required a two (2) person assist, two (2) residents required a Hoyer lift for transfers, eight (8) residents required a one (1 ) person assist with activities of daily living, and four (4) residents required feeding assistance. The staff schedule for April 2020 reflected there was one (1) caregiver and one (1) med tech on the a.m. shift and the p.m. shift, and two (2) caregivers on the overnight shift. Information obtained through interviews found that the caregivers also had to perform housekeeping and laundry duties. Management and staff interviews revealed that there was not an adequate amount of staff and that the staffing budget had been cut by corporate due to the low amount of admissions to the facility. Interviews also revealed that at times there were no staff present with the residents in the dining and common areas due to staff were attending to other residents in their rooms. Based on the information obtained, the allegation is deemed substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20200427131223

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: 03/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/11/2022 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	H&S 1569.312(a) Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by: Based on interviews and records review,	1 2 3 4 5 6 7	Licensee is currently hiring more staff to cover staff that are working overtime, hire a part time per diem person as needed. Interim administrator provided copies of job recruitment to LPA during inspection. Facility is seeking to hire 3 part time staff and 1 full time staff. PoC is cleared.
	8 9 10 11 12 13 14	the licensee did not comply with the section cited above. Licensee failed to provide adequate care and supervision to R1 which attributed to R1’s aggressive, assaultive incidents on 04/25/2020 and 04/26/2020,which posed an immediate health, safety, or personal rights risk to person in care.	8 9 10 11 12 13 14
Type A 03/11/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit staff schedule showing adequate staffing to CCL by 3/11/22 to LPA. Staff schedule was received by LPA during inspection for review.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. Licensee failed to provide adequate staffing to care for thirteen (13) dementia residents, which posed an immediate health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 6

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
04/27/2020 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20200427131223

FACILITY NAME:	PACIFICA SENIOR LIVING SANTA BARBARA		FACILITY NUMBER:	425802116
ADMINISTRATOR:	ONYEBUCHI, AHAOMA N		FACILITY TYPE:	740
ADDRESS:	325 W ISLAY ST		TELEPHONE:	(805) 898-2650
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93101
CAPACITY:	36	CENSUS: 21	DATE:	03/10/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Miriam Santiago		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
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9

Staff not following resident admission procedures.

INVESTIGATION FINDINGS:

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On 3/10/2022 at 9:20 a.m., Licensing Program Analyst (LPA) Toan Luong conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Business Office Manager Miriam Santiago acting as interim administrator and explained the reason for the visit.

On 04/27/2020, the Department received a complaint alleging “Staff not following resident admission procedures”.

On 05/06/2020, from 9:00am to 11:30am, LPA Kristin Kontilis initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with Mary Moore, Executive Director. At approximately 9:10am through 11:10am, LPA Kontilis conducted telephone interviews with Miriam Santiago, Business Office Manager and Mary Moore, Executive Director.
(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20200427131223

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: 03/10/2022

NARRATIVE

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SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 6