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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802116
Report Date: 12/14/2022
Date Signed: 12/14/2022 05:38:12 PM


Document Has Been Signed on 12/14/2022 05:38 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: DATE:
12/14/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Miriam Santiago, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Plan of Correction (POC) visit to the above-named facility. LPA arrived at approximately 3:35 pm. LPA met with Miriam Santiago, Administrator and explained the purpose of the visit.
During a visit on 11/5/2022, the facility was issued a citation for not submitting serious illness/injury reports to CCL for Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), Resident 4 (R4), and Resident 5 (R5) within seven (7) days of their occurrence. Citation was issued on 12/5/2022 with a plan of correction date of 12/6/2022. The plan of correction was not received as of 12/14/2022.
The plan of correction for serious illness/injury reports have not been received for the incidents that occurred on 11/26/2022 for R1, R2, R3, R4, and R5; and Administrator has not submitted a written statement acknowledging intention to comply with CCR87211 as agreed upon. Therefore, LPA is conducting a Plan of Correction visit to issue civil penalties.

Civil penalties are being assessed today in the amount of $800 ($100 x 8 days) for not submitting a plan of correction for deficiency issued on 809-D, dated 12/5/2022. Civil penalties will continue to accrue until proof of correction has been received by CCL.

Exit interview conducted. Civil penalty assessed. Appeal Rights discussed. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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