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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610025
Report Date: 01/13/2025
Date Signed: 01/13/2025 01:41:42 PM

Document Has Been Signed on 01/13/2025 01:41 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PACIFICA SENIOR LIVING NORTHRIDGEFACILITY NUMBER:
197610025
ADMINISTRATOR/
DIRECTOR:		IVY MITCHELL SHARPFACILITY TYPE:
740
ADDRESS:8700 LINDLEY AVENUETELEPHONE:
(818) 886-5181
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 110CENSUS: 77DATE:
01/13/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:13 AM
MET WITH:Resident Care Director, Francis NorberteTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On 01/13/25, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit (31-AS-20250106161520) and was greeted by Resident Care Director, Francis Norberte. While interviewing residents, LPA was informed that there was also no Activities Director. While conducting the physical tour, LPA asked to speak to the Activities Director and was informed there is no current activities director.

LPA interviewed six (6) staff that confirmed there is no Activities Director and the previous Activities Director left November of 2024.

An exit interview was conducted, a citation(s) was issued for the above allegation(s), appeal rights and a copy of this report was given to the Resident Care Director.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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 01/13/2025 01:41 PM - It Cannot Be Edited


Created By: Gina Saucedo On 01/13/2025 at 11:18 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING NORTHRIDGE
FACILITY NUMBER: 197610025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2025
Section Cited
CCR
87219(f)

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87219 (f) Planned Activites:
In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities...The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers. This requirement is not met by:
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The Licensee shall hire or designate an activities director by POC:01/27/25 and send employee qualifications to Community Care Licensening Department/LPA Saucedo.
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Based on the observation and staff/resident interviews the licensee did not ensure an activities director/one full time staff member to be at the above facility which poses a potential Health, Safety or Personal Rights risks to person 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:Troy Agard
LICENSING EVALUATOR NAME:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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