425802116-6-11-2024-29-AS-KBUY-D6F5AS-20240620194738

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 06/11/2024
Date Signed: 06/11/2024 04:26:09 PM

Unsubstantiated

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
02/27/2024 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20240227112010

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:	06/11/2024
		UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Cynthia Garcia, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff do not ensure that residents are provided activities while in care.
Staff do not adhere to resident's special diet as prescribed.
Staff do not ensure that resident is provided their medication(s) as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to deliver final findings for the above allegation. LPA Philips started the investigation on 3/6/2024 from 1:30pm to 3:30pm. During today’s visit, LPA Rankin met with Cynthia Garcia, administrator, and Elizabeth Hernandez, Designee, explained the reason for the visit. LPA toured the facility, reviewed relevant documents, and interviewed administrator, staff, and residents.

On the allegation: Staff do not ensure that residents are provided activities while in care. It was alleged that activities were not provided. However, reporting party also stated activities are provided, but they thought the activities could be improved. On 3/6/2024, LPA observed activities available for residents including board games, puzzles and reading materials in the common room. Continued on 9099-C

Unsubstantiated

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: 06/11/2024

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)

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Control Number 29-AS-20240227112010

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 5/6/2024, 6/3/2024 and 6/11/2024, LPA observed activities occurring in the common room area. Administrator provided an activities calendar and stated they typically follow the calendar closely, unless one activities is more engaging or preferred by residents. Residents interviewed stated they liked the activities provided and usually participate. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff do not adhere to resident's special diet as prescribed. It was alleged that Resident 1(R1) had a special diet prescribed as a result of a medication being taken, but the special diet was not implemented. LPA reviewed the special diet forms in the facility and did not observe one for R1. Administrator and memory care director fill out the forms, sign it and have the dietary director sign. The form includes the resident’s name, picture, special diet description and effective date. Administrator stated they clarify special diet orders when needed, such as recently clarifying a “no dessert” order to see if fruit or sugar free ice cream was acceptable. Administrator stated they immediately review orders for special diets and implement them. LPA reviewed R1’s file and did not see an official order for a special diet. However an after visit summary did indicate a bland diet after vomiting. R1’s responsible party did not respond to LPA’s request for interview. Based on the information obtained, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff do not ensure that resident is provided their medication(s) as prescribed. It was alleged that medication information was not passed between shifts. Administrator stated they use end of shift reports to communicate information about residents to the next shift. Administrator stated when a new medication or order is received, the order is usually faxed or emailed to the facility. Alternatively, if the order is sent directly to the pharmacy, they follow up with the pharmacy and/or doctor to obtain a copy of the written order. Administrator stated updates in orders get updated directly in their Quickmar system. Administrator stated if medications are discontinued, the medications get archived in the Quickmar.

Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (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 3

Control Number 29-AS-20240227112010

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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When staff notice that a medication is discontinued, they turn the bubble pack around and bring it up to management. The resident care coordinator or memory care directly pull the bubble packs and follow discontinued medication procedures to destroy it. New orders are also put in the binder sticking out to notify other staff of changes. LPA reviewed medications and observed discontinued medications in the Quickmar. Based on the information obtained, there was insufficient evidence to prove the allegation occurred. Therefore the allegation is deemed Unsubstantiated at this time.

Exited interview done, copies of report given to Designee.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (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)

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