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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 06/11/2024
Date Signed: 06/11/2024 12:12:24 PM

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
12/01/2022 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20221201151546
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: 14DATE:
06/11/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Cynthia Garcia, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not ensure a safe environment for residents in care.
Staff did not ensure a sanitary environment for residents in care.
Staff did not ensure that residents were provided with clean linens while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to deliver final findings for the above allegation. The initial visit was conducted on 12/5/2022 by LPA Kristin Kontilis. During the investigation, LPA toured the facility and interviewed staff. LPA also collected and reviewed relevant documents. During today’s visit, LPA Rankin met with Cynthia Garcia and explained the reason for the visit.
On 11/26/2022, facility staff called first responders for assistance due to a resident falling. Multiple first responder agencies visited the facility as a result of this incident. Multiple patients were taken to hospital due to concerns for their health and safety.

On the allegations: Staff did not ensure a safe environment for residents in care, and Staff did not ensure a sanitary environment for residents in care. 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: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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 6
Control Number 29-AS-20221201151546
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: 06/11/2024
NARRATIVE
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A credible witness (W1) observed a dirty diaper in the facility hallway. W1 observed one room to have old, dried feces that appeared to be more than a day old as it was hard and thick. A bathroom room of two resident had black feces in the toilet still appeared to have not been flushed for hours. W1 also observed feces on the main hallway that was old, hard and dried. Another bathroom had an old, used diaper lying next to the toilet. Former Administrator reported staff check residents and their rooms every 2 hours, and some residents every hour, but these health and safety issues were observed and appeared to be at least one day old. The facility had no cleaning logs. W1 indicated Former Administrator discussed the diapers in the hallway with staff, and they did not have an excuse or reason, and admitted this was not accepted. Former Administrator reported cleaning occurs once per week by a housekeeper, and they also have developmentally disabled volunteers assist with cleaning. Former Administrator reported facility was cleaned three times per week, but admitted areas must have been missed and agreed it was a health hazard. LPA observed photographs of the dried feces on the floor, the unflushed toilet. Based on the information obtained, the facility did not provide a safe or sanitary environment for the residents. Therefore the allegation is deemed Substantiated at this time.

On the allegation: Staff did not ensure that residents were provided with clean linens while in care. A credible witness observed one room had bed linen covered with some blood and had not been cleaned. LPA observed a photograph of the soiled linen. Based on the information obtained, the allegation is deemed Substantiated at this time.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20221201151546
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: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2024
Section Cited
CCR
87303(a)
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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:
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Manager will provide a written statement of understanding of 87303.
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Based on interviews and observations, the licensee did not comply with the section when the facility was not clean or safe, which posed a 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: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
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
12/01/2022 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20221201151546

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: 14DATE:
06/11/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Cynthia Garcia, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Due to staff neglect, Resident(s) suffered a fall resulting in injury.
Staff did not respond to resident's change of condition in a timely manner.
Staff did not meet the needs of residents in care.
Facility staff provided inadequate supervision to residents.
INVESTIGATION FINDINGS:
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On the allegation: Due to staff neglect, Resident(s) suffered a fall resulting in injury. It was alleged that credible witnesses found one resident (Resident 1 – R1) down on the found, and another resident (Resident 2 – R2) face down while treating the first resident. Per credible witness interview with Former Administrator at time of incident, R1 fell and hit their head on 11/26/2022. Later in the day, R1 became unresponsive so staff called 9-1-1. R2 was observed down while first responders were in the building treating R1. Former Administrator stated they believed R2 should not have been taken as they were discharged back the same day. Records and interview did not indicate any serious injury for R1 or R2. Therefore the allegation is deemed Unsubstantiated this time.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20221201151546
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: 06/11/2024
NARRATIVE
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On the allegation: Staff did not respond to resident's change of condition in a timely manner. It was alleged that credible witnesses found one resident (Resident 1 – R1)down on the found. Per credible witness interview with Former Administrator at time of incident, R1 fell and hit their head on 11/26/2022. Later in the day, R1 became unresponsive so staff called 9-1-1. Once R1’s change in condition of unresponsiveness occurred, facility staff contacted 9-1-1 for additional assistance. Staff notified first responders of other medical issues that occurred while first responders were present. Although the allegation may have occurred, there was insufficient evidence to prove it. Therefore the allegation is deemed Unsubstantiated at this time. Technical assistance is provided to remind the facility to observe residents who hit their head, and of their responsibility to seek timely medical attention despite residents may not be reliable narrators due to their dementia diagnoses.

On the allegation: Staff did not meet the needs of residents in care. It was stated that multiple residents were found dehydrated and possibly malnourished. Other interviews conducted stated staff always put liquids in front of residents and encourage them to drink. Staff also stated residents refusing to eat is reported to management, where it will be addressed with the resident’s physician. A credible witnesses found one resident (Resident 1 – R1) down on the found. Per credible witness interview with Former Administrator at time of incident, R1 fell and hit their head on 11/26/2022. Later in the day, R1 became unresponsive so staff called 9-1-1. Resident 4 (R4) was found on the toilet unresponsive, and staff asked first responders to evaluate R4 due to the unresponsiveness. R4 was transported to the hospital as well. Resident 2 (R2) was observed down while first responders were in the building treating R1. Former Administrator stated they believed R2 should not have been taken as they were discharged back the same day. Records and interview did not indicate any serious injury R2. Resident 3 (R3) was then observed by staff to have difficulty breathing and first responders observed it as well so R3 was transported to the hospital. Former administrator reports that family and staff were aware of R3’s breathing issues and were managing their medical care, and R3’s family did not want them to go to the hospital.
Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20221201151546
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: 06/11/2024
NARRATIVE
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Former Administrator stated Resident 5 (R5) was also transported due to an injury to their hand (fractured finger) but R5 previously had the fall and broken finger, and R5 was on hospice so they should not have been transported. Following the incident, a credible witness visited the facility. They observed 21 residents, mostly in the common areas. Residents appeared to be wearing clean clothes, well-groomed, good hygiene, and no smell of urine or feces was detected or observed. LPA reviewed incident reports submitted around the time of the complaint. On 11/26/2022, the Administrator performed mass COVID-19 testing and found nineteen of the twenty residents were positive for COVID-19. Although it is unusual that multiple residents would require medical attention at once, the allegation was unable to be proven conclusively. Therefore the allegation is deemed Unsubstantiated at this time.

On the allegation: Facility staff provided inadequate supervision to residents. Per a credible witness’ interview, Former Administrator indicated for the 21 residents, during the day there are 3 care staff and there are 2 overnight. A credible witness observed 21 residents, mostly in the common areas. Residents appeared to be wearing clean clothes, well-groomed, good hygiene, and no smell of urine or feces was detected or observed. Although many issued occurred when first responders were at the facility, there was insufficient evidence found to prove that it was a result of inadequate supervision. Therefore the allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6