425802116-6-3-2024-29-AS-KBUY-D6F5J6-20240620195925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 06/03/2024
Date Signed: 06/03/2024 10:33:12 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
06/28/2023 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20230628132443

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:	06/03/2024
		UNANNOUNCED	TIME BEGAN:	10:09 AM
MET WITH:	Esmeralda Perez, Med Tech		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility did not give a refund to a prospective residents after deciding not to move in.

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 Esmerlda Perez, Medical Technician 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: Facility did not give a refund to a prospective residents after deciding not to move in. It was alleged that two residents had planned to move in and paid a pre- admission fee. Continued on 9099-C

Substantiated

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: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

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-20230628132443

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: 06/03/2024

NARRATIVE

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However, the residents’ pre-admission fees were not refunded despite never moving in and not signing an admission agreement.

Residents’ responsible party indicated they contacted the facility in May 2022, and communicated with Administrator Miriam Santiago and Regional Director Brittnee Kreymer-Austin. They were informed the facility had two rooms available, but insisted they needed to apply immediately, including paying a community fee and base cost as of May 31, 2022. Responsible party paid by credit card to hold the rooms and received the receipt by email. Resident 1 (R1) paid $3776.10 on 5/13/22 and Resident 2 (R2) paid $1726.10 on 5/12/22. The two residents never moved in, and one passed away in June 2022. Responsible party contacted Administrator and Regional Director by phone and email to state the remaining resident would not move in. Responsible party stated the June 2022 fees were abated and they were released from the rooms July going forward; however, the community (pre-admission) fee was never refunded.

Administrator Santiago was interviewed on 6/29/23. Administrator indicated she personally did not take the payment for the pre-admission fee. She stated she would request they send out a refund. On 5/30/2024, facility manager confirmed the community fees for R1 and R2 should have been refunded, but they were not. Facility manager was working with their accounting department to get the refund issued.

Based on the information obtained, the allegation Facility did not give a refund to a prospective residents after deciding not to move in is Substantiated at this time.

Exit interview conducted, deficiency cited on 9099-D, copy of report given, appeal rights given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230628132443

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: 06/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/11/2024 Section Cited CCR 87507(g)(5)(E)(1)(a)	1 2 3 4 5 6 7	Admission Agreements. A 100 percent refund of a preadmission fee shall be provided…if: The applicant decides not to enter the facility…This requirement was not met as evidenced by: Based on record	1 2 3 4 5 6 7	Facility manager is working with accounting department to issue the refund. Facility manager will provide proof the refund was issued to CCL by June 11, 2024.
	8 9 10 11 12 13 14	review and interview, the licensee did not comply with the section cited above when a refund was not issued to prospective residents, which posed a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2024

LIC9099 (FAS) - (06/04)

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