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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802116
Report Date: 03/10/2022
Date Signed: 03/10/2022 11:03:12 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/23/2020 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20201223100705
FACILITY NAME:PACIFICA SENIOR LIVING SANTA BARBARAFACILITY NUMBER:
425802116
ADMINISTRATOR:ALLAMARY E. MOOREFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 898-2650
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 21DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Miriam SantiagoTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Facility failed to issue a refund.
Facility failed to provide a copy of the signed Admission Agreement to Resident or the Resident’s Representative upon Resident’s admission into the facility.
INVESTIGATION FINDINGS:
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On 3/10/2022 at 10:30 a.m., Licensing Program Analyst (LPA) Toan Luong conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Business Office Manager Miriam Santiago acting as interim administrator and explained the reason for the visit.

On 12/23/2020, the Department received a complaint (#29-AS-20201223100705) alleging “Facility failed to issue a refund” and “Facility failed to provide a copy of the signed Admission Agreement to Resident or the Resident’s Representative upon Resident’s admission into the facility.”

On 12/30/2020, at 1:13pm, Licensing Program Analyst (LPA) Kristin Kontilis initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with Allamary Moore, Administrator and Miriam Santiago, Business Director.
(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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 3
Control Number 29-AS-20201223100705
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022
NARRATIVE
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From approximately 1:15pm to 2:00pm, LPA Kontilis conducted interviews with Ms. Moore and Ms. Santiago and requested copies of documents pertinent to the investigation. On 12/30/2020, from 11:47am to 2:00pm, LPA Kontilis conducted interviews with the Reporting Party, Administrator, and Business Director. From 02/17/2022 at 9:56am through 02/22/2022 at 2:34pm, LPA Lyndia Sager conducted interviews with the Business Director and the Reporting Party. On 02/17/2022, at 10:06 am, LPA Sager requested a copy of R1’s refund for the period of 10/11/2020 through 10/31/2020.

On the allegation: Facility failed to issue a refund – On 10/09/2020, R1 passed away at the facility while on hospice. R1’s Representative had previously paid $6,800.25 for the month of October 2020. Per the Business Director, R1’s Representative removed R1’s personal belongings on 10/10/2020. R1’s Representative requested a refund for the remaining days of October 2020. Per interviews with the Administrator and Business Director, once a request for a refund is sent to the Corporate office, it can take up to 90 days to process. LPA Sager reviewed the refund statement from the Pacifica Senior Housing Accounting Department. The statement indicates the refund check for $4,623.39 was mailed to R1’s Representative on 01/25/2021. LPA Sager confirmed with R1’s Representative that they received the refund check in January 2021.

On the allegation: Facility failed to provide a copy of the signed Admission Agreement to Resident or the Resident’s Representative upon Resident’s admission into the facility – On 09/16/2019, R1 was admitted to the facility. LPA Sager reviewed R1’s admission agreement, which was signed by R1’s Representative and dated 09/16/2019. The admission agreement was also electronically signed by former Administrator Katrina Pennington. Per information obtained through interviews, R1’s Representative stated they were promised a copy but never received a copy of R1’s admission agreement. Per the Business Director, there is no documentation available that a copy of R1’s admission agreement was given to R1’s Representative.

Based on the information obtained through records review and interviews, the allegations “Facility failed to issue a refund” and “Facility failed to provide a copy of the signed Admission Agreement to Resident or the Resident’s Representative upon Resident’s admission into the facility” are deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20201223100705
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2022
Section Cited
HSC
1569.652(c)
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H&S 1569.652(c) Termination of admission agreement upon death of resident...
(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...within 15 days after the personal property is removed.
This requirement is not met as evidenced by:
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Licensee will submit plan to ensure resident refunds are met per H&S 1569.652(c). LPA reviewed Health and Safety code 1569.652(c) with Interim administrator, and interim administrator will send LPA proof that communication of health and safety code was communicated with the corporate office by 3/17/22.
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Based on interviews and records review, the licensee did not comply with the section cited above. Licensee failed to provide R1’s Representative with a refund within 15 days after R1 passed away and personal belongings removed, which posed a potential health, safety, or personal rights to residents in care.
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Type B
03/17/2022
Section Cited
CCR
87507(e)
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87507(e) Admission Agreements
(e)The licensee shall provide a copy of the signed and dated current admission agreement... immediately upon signing the admission agreement or modification...shall provide additional copies to the resident or resident’s representative upon request.
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Licensee will submit plan to ensure a resident or Resident Representative receives a copy of the Admission Agreement immediately upon signing the agreement or modification to the agreement. Interim administrator will send LPA plan by 3/17/22.
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Licensee failed to provide R1’s Representative with a copy of R1’s Admission Agreement, which posed a potential health, safety, or personal rights 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: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3