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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 07/05/2022
Date Signed: 07/05/2022 03:52:46 PM


Document Has Been Signed on 07/05/2022 03:52 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:ALLAMARY E. MOOREFACILITY TYPE:
740
ADDRESS:325 W ISLAY STTELEPHONE:
(805) 898-2650
CITY:SANTA BARBARASTATE: CAZIP CODE:
93101
CAPACITY:36CENSUS: 22DATE:
07/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Anais Ochoa, Med TechTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted a Case Management visit in conjunction with a complaint visit (Complaint Control # 29-AS-20220627170949. LPA met with Anais Ochoa, Medication Technician. Administrator Miriam Santiago was not available at the time of today’s visit. The purpose of the visit is to issue citation(s) for deficiencies observed during the complaint investigation.

Entrance interview conducted:
During a previous visit to the facility on 6/17/2022, LPA observed an abandoned washing machine sitting next to the recycling and trash bins of the facility. On 6/17/2022, Administrator Santiago stated the facility purchased a new washing machine and the abandoned washing machine would be removed by the end of business day on 6/17/2022.

Upon arrival to the facility for today’s visit at 1:06 pm LPA observed the abandoned washing machine had not been removed and remains to be visible to residents in care, staff, visitors to the facility and to those who passersby on foot and or by vehicle. Based on LPA's observations, the facility failed to maintain a clean environment at all times.

Exit interview conducted. Copy of report and Appeal Rights issued via email to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/05/2022 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2022
Section Cited

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87303(a) 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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Based on LPAs observation, the licensee did not comply with the section cited above as LPA observed an abandoned washing machine in front of the facility visible to residents in care, visitors to the facility, staff, and public individuals passing by which poses 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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2