425802116-1-30-2024-29-AS-KKOS-CZZ3TF-20240130173152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 01/30/2024
Date Signed: 01/30/2024 05:32:06 PM

Document Has Been Signed on 01/30/2024 05:32 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 BARBARA		FACILITY NUMBER:	425802116
ADMINISTRATOR:	KAREN DACOME		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:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Cynthia Garcia, Business Office Director		TIME COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Annual Required Inspection of the facility. At the time of arrival, there were two (2) staff on duty and fourteen (14) residents in care. LPA met with Cynthia Garcia, Business Office Director (BOD), and explained the purpose of the visit. Entrance interview conducted: The facility is a one-story Residential Care Facility for the Elderly (RCFE) with a capacity of thirty-six (36) residents. The facility is a memory care facility for residents with a dementia diagnosis. The facility has a fire clearance for thirty-six (36) bedridden residents and a hospice waiver for ten (10) residents. Currently, there are no residents on hospice and no bedridden residents residing in the facility. LPA and BOD toured the facility to assess the physical environment and accommodations. The following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. Upon entry, there is a gate that requires a code to enter the premises and a phone number posted to the facility for those who do not have a code. Entering through the gate, is a large walkway and driveway leading up to a large front patio with seating areas including patio chairs, tables with umbrellas, couches, and mini-couches. Entering past the patio area, the administrator’s office is located on the west side of the building. Staff files and other confidential information is kept in the administrator’s office. Entering into the main area of the facility is the dining area/common area on the east side of the room. Socializing, meals, and activities are held in the dining/common area. The kitchen is located at the back of the dining/common area and is inaccessible to residents in care. LPA observed seven (7) days of non-perishable food items and two (2) days of perishable food items. LPA also observed an ample amount of emergency and frozen foods. The medication room is located on the west side of the facility just past the main entry. The medication room requires a code to enter the room. Residents’ medications, residents’ files, and first aid kit are kept in the medication room. The medication room overlooks the common area. <Please continue to 809-C, Pg 2

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/30/2024

NARRATIVE

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Past the medication room is a hallway that leads to residents’ rooms, bathrooms, and shower rooms. There are twenty-four bedrooms and three (3) full showers located off the hallways. Each bedroom is equipped with a sink in the bedroom and a toilet room. The bedrooms were inspected and found to have sufficient bedding, lighting, and storage for each resident in care. Each room has individual temperature control to be adjusted to the resident's comfort level. The three shower rooms are set up for residents to be taken into the shower room for showers while staying in their wheelchair. The shower rooms have non-slip flooring and grab bars for the residents and there are shower chairs the residents can utilize. The Facility maintains five (5) working carbon monoxide detectors and approximately eight (8) smoke detectors all in good working order.
From approximately 2:55 pm to 3:05 pm, LPA and BOD observed foul odors in the bathrooms of Bedrooms 4 and 5 and the Bedrooms 9 and 16.
From approximately 3:15 pm to 3:17 pm, LPA and BOD observed five fire extinguishers were last serviced on 1/5/2023.
Due to time restraints, LPA will return at a later date to continue the annual inspection.

Exit interview conducted. The following deficiencies were observed (see LIC809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil penalty issued at the time of the visit.

Failure to correct the deficiencies by the correction due date may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were 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: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2024 05:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as fire inspection service on five out of five fire extinguishers was expired as of 1/5/2023, which poses an immediate heatlh and safety risk to residents in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	Licensee agrees to purchase and install 3 fire extinguishers and install with proof of purchase no later than 5:00 pm on 1/31/2024.

Type A

Section Cited

CCR

87303(a)

87303(a) MAINTENANCE AND OPERATION: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as out of 14 residents rooms and bathrooms, two residents’ bedrooms and two residents' bathrooms had foul odors which poses an immediate health and safety risk to residents in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	POC: Licensee agrees to conduct daily periodic checks to ensure rooms are clean, safe, sanitary and in good repair at all times. Staff cleaned bedrooms and bathrooms by the end of the inspection. POC cleared on this date.

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: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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