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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 09/16/2022
Date Signed: 09/16/2022 01:46:01 PM


Document Has Been Signed on 09/16/2022 01:46 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: 19DATE:
09/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Miriam Santiago, Interim AdministratorTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced case management visit to issue deficiencies discovered during the investigation of 29-AS-20220627170949.
On 7/5/2022, LPA conducted a visit to the facility. LPA observed the Administrator on record was on leave and the Interim Administrator was on vacation. LPA observed no designated substitute placed in charge at the time the visit was conducted, although LPA learned there was coverage the week before. Previously, Amanda North, Executive Director/Operations Specialist had covered, and LPA requested documents. North stated in an email to the LPA on 7/5/2022 at 5:10pm that she was only filling in for a brief period and the point of contact would be the Interim Administrator (who was on vacation).
On 7/5/2022, Administrator on record notified LPA their last day at the facility was on 7/19/2022. Administrator Allamary Moore had been on leave since 10/1/2021. On 1/19/2022, LPA requested documents naming the new administrator. On 1/19/2022, Interim Administrator Miriam Santiago provided partial documents required to name Santiago as the new administrator. On 1/19/2022, at 1:57 pm, Santiago sent a request via email to Marleen Nelson, Director of Regulatory Compliance requesting the required documents to name Santiago as an Interim Administrator and/or Administrator. On 7/18/2022, Santiago sent an email to Brian Perine, Regional Operations Director and Kelly Hatter, Vice-President of Operations, Etros Management Company requesting the required documents to name Santiago as an Interim Administrator and/or Administrator. On 9/16/2022, Santiago stated she sent an email to Mandy Taylor, LVN, Regional Director of Operations, Pacifica Senior Living, Inc.
On this day, at approximately 11:09 am, LPA observed Staff 1 (S1) wearing a face mask partially covering their face. LPA observed S1 enter the medication room where S1 pulled the mask over their face properly covering S1's nose and mouth. At approximately 11:10 am, LPA observed S1 walking down the hallway, observing a resident with S1's mask only partially on S1's face, not covering the nose area.
Please continue to 809-C, Pg 2.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
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 09/16/2022 01:46 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: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2022
Section Cited

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§1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling : (b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator
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This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure a designated substitute on the premises 24 hours per day, 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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2022 01:46 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: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/19/2022
Section Cited

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87468.1 (a)(2) Personal Rights of Residents in all Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Based on LPA’s observation, the licensee did not comply with regulation above when Staff 1 and Staff 2 were present in the facility without wearing masks fully covering the mouth and nose which poses an immediate health, safety, and 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: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


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
VISIT DATE: 09/16/2022
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 At approximately 11:11 am, LPA observed Staff 2 (S2) assisting a resident in the common area with S2's mask only partially covering S2's face, not covering the nose area. LPA requested Interim Administrator Santiago to instruct S2 on properly wearing the mask covering nose and mouth. Santiago complied with LPA's request.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Exit interview conducted. Copy of report and appeal rights issued via email.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC809 (FAS) - (06/04)
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