<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 11/14/2022
Date Signed: 11/14/2022 04:12:32 PM

Document Has Been Signed on 11/14/2022 04:12 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 BARBARAFACILITY NUMBER:
425802116
ADMINISTRATOR:MIRIAM SANTIAGOFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 898-2650
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY: 36CENSUS: 20DATE:
11/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Miriam Santiago, AdministratorTIME COMPLETED:
04:10 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 visit to the facility. While investigating complaint # 29-AS-2022110412253523, LPA Kontilis noted the following deficiencies.

Upon arrival into the facility, LPA observed Administrator Miriam Santiago in the common area near the kitchen area was not wearing a face covering. Several residents were in the common area with one resident within close proximity to Administrator. LPA asked Administrator why she wasn’t wearing a face covering. Administrator stated she had come out into the common area temporarily. LPA observed Administrator enter into the medication room to secure a mask then put it on.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):

Exit interview conducted. Copy of report and Appeal Rights issued via email.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/14/2022 04:12 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 11/14/2022 at 03:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2022
Section Cited
CCR
87468.1(a)(2)

1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
1
2
3
4
5
6
7
Administrator agrees to conduct an infectious control training, review and train staff on all recent PIN’s released for 2022, including mask-wearing mandates, and provide copy of training and staff signatures to CCL by 11/16/2022. Signatures to include first and last name.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on observation, the facility failed to ensure Administrator/staff were wearing face coverings which poses an immediate health, safety and 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
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2