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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 05/06/2024
Date Signed: 05/06/2024 10:54:13 AM

Substantiated


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
09/05/2023 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20230905123221
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: DATE:
05/06/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff did not follow infection control procedures.
Facility did not provide residents basic supplies.
Facility is not clean.
Facility is in disrepair.
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 ______ and explained the purpose of the visit.

During the investigation, LPA Kontilis conducted an initial visit on 9/11/2023, toured the facility, interviewed staff from 10:40am to 4:00pm, and obtained documents. LPA conducted additional visits on 9/12/2023 from 12:30pm to 6:30pm and 9/18/2023 from 10:55am to 11:40am.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (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)
Page: 1 of 5
Control Number 29-AS-20230905123221
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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On the allegation: Facility staff did not follow infection control procedures. It was alleged that during a COVID-19 outbreak, the facility’s cleaning supplies were locked up and inaccessible to staff. Therefore staff could not properly disinfect and following infection control procedures. Staff interviewed stated over Labor Day weekend, they were unable to access the cleaning supplies in the laundry room and therefore could not properly disinfect. Based on the evidence obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility did not provide residents basic supplies. It was alleged that the key to the laundry room was lost, and therefore staff did not have access to cleaning supplies, laundry facilities, towels or toilet paper.
Multiple staff interviewed confirmed over Labor Day weekend, they did not have the key to the laundry room and could not access it. Staff confirmed they did not have access to towels, toiletries, toilet paper, tissues, or cleaning supplies. Staff stated they reported the lack of access to the Memory Care Director when they came on shift and realized the keys were missing. Staff confirmed a visitor brought toilet paper in for the facility. Visitor interviewed stated they brought in one roll of toilet paper for a resident on 9/2/23 and on 9/3/23 brought in a 48-roll pack of toilet paper for all residents. LPA reviewed a locksmith invoice dated 9/5/23. The invoice indicates a mobile locksmith call and new knobset was installed. Based on the evidence obtained, the allegation is deemed Substantiated at this time.
On the allegations: Facility is not clean and Facility is in disrepair. It was alleged that a resident’s toilet was clogged for at least four days, and a resident’s toilet was dirty for at least a week with feces present on it. Visitors were interviewed, who stated R1’s toilet was clogged with feces over Labor Day weekend. Visitors stated the facility was unable to get a plumber to fix it until the Tuesday after the holiday. Staff interviewed confirmed the facility had plumbing issues prior to Labor Day weekend and a plumber had already visited the facility. The plumber fixed the plumbing in Room 1, but then later multiple other rooms backed up. Staff stated the plumber came back two to three times to the facility to fix it. Staff stated the facility has a chronic ongoing issue with the plumbing, possibly due to residents putting items or wipes down the toilets.
Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (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)
Page: 2 of 5
Control Number 29-AS-20230905123221
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 reviewed a plumbing invoice dated Thursday 8/31/23 to fix Room 25, which corroborates that a plumber started addressing the issues prior to Labor Day weekend.

Visitors interviewed indicated one resident’s room has a broken heater, and the ceiling has water damage due to a previous leak. LPA during walk thru on 5/6/24 observed water damage to ceiling is still present and it was requested that proof of heater functioning be provided.

Staff stated the laundry room wasn’t locking for approximately one month, and the medication room door does not securely lock. During the tour, LPA Kontilis observed the medication room handle, and staff demonstrated the door does not stay locked unless the handle is held up when closing it. During the tour, LPA Kontilis also observed a broken doorknob in Room 4. The door handle inside the room fell off when pulling the door closed, which could pose a danger to residents. During walk thru on 5/6/24 LPA found that multiple keys have been obtained and other work around for possible lock outs have been planned as well as there was no loose door handles noted at this time. Based on the evidence obtained, the allegation is deemed Substantiated at this time.

Exit interview conducted, copy of report given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (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)
Page: 3 of 5
Control Number 29-AS-20230905123221
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2024
Section Cited
CCR
87470(b)(1)
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Infection Control Requirements…Staff…shall be required to perform enhanced environmental cleaning and disinfection to maintain a safe and sanitary environment... This requirement is not met as
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Facility provided locksmith invoice showing lock was repaired/replaced. POC cleared during visit.
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evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when disinfectants and cleaning supplies were not available during a COVID outbreak,
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 which posed an immediate health and safety risk to residents in care.
Type A
05/07/2024
Section Cited
CCR
87307(a)(3)
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Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. This requirement
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Executive director showed LPA that multiple keys are availiable. POC cleared during visit.
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is not met as evidenced by: Based on interviews, the licensee did not comply with the section when the facility could not access toilet paper, towels, hygiene or cleaning products, which posed an immediately health
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and safety risk to residents in care.
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: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230905123221
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2024
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on
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Executive director will provide written proof that the heater and ceiling have been fixed in room 16.
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interviews and observations, the licensee did not comply with the section when the facility was not clean or in good repair, which poses potential 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: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5