197610025-2-20-2025-31-AS-NMAN-DF4VSC-20250325164118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610025
Report Date: 02/20/2025
Date Signed: 02/20/2025 11:04:05 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2024 and conducted by Evaluator Leizl De La Cerra

COMPLAINT CONTROL NUMBER: 31-AS-20241227112439

FACILITY NAME:	PACIFICA SENIOR LIVING NORTHRIDGE		FACILITY NUMBER:	197610025
ADMINISTRATOR:	IVY MITCHELL SHARP		FACILITY TYPE:	740
ADDRESS:	8700 LINDLEY AVENUE		TELEPHONE:	(818) 886-5181
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	110	CENSUS: 75	DATE:	02/20/2025
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Karen Marin, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Due to water leakage there were molds on the floors and walls.
Facility freezer is not maintaining the required temperature.
Call buttons in residents rooms and bathrooms are missing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced subsequent complaint visit to this facility to investigate the above allegation and deliver findings. At 10:30AM, LPA met with the facility executive director, Karen and explained the reason for the visit.

Regarding the allegation: Facility freezer is not maintaining the required temperature.
It has been alleged that on Dec. 4, 2024 the facility walk-in freezer is not maintaining the required temperature. To investigate this complaint, On 1/2/2025 at 11:00am, LPA conducted an initial complaint visit, LPA toured the physical plant, conducted interview with staff members and facility residents between 12:00PM to 4:00PM. LPA requested pertinent documents/records and conducted record reviews between 12:00PM to 4:00PM.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 31-AS-20241227112439

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 NORTHRIDGE	FACILITY NUMBER: 197610025
	VISIT DATE: 02/20/2025

NARRATIVE

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During the initial visit on 1/2/25, LPA observed the walk-in freezer maintaining the required temperature of 0 degrees Fahrenheit, which is in compliance with the Title 22 Regulation, 87555 - General Food Service Requirements section. LPA took a picture of the temperature sensor which shows a -5 degrees F.
LPA was also provided a copy of an invoice of a purchase of a new motor for the walk in freezer, invoice was dated Dec. 09, 2024. Furthermore, LPA interviewed four (04) facility staff members, S1, S2, S3 and S4 and all confirmed that on 12/04/2024, when the walk-in freezer was not working, all frozen items from the walk in freezer was transferred to the back-up freezer located in the dining area. LPA took a picture of the back-up freezer. During the subsequent visit on 2/20/25 LPA checked the walk-in freezer once again and observed the walk-in freezer maintaining the required temperature of 0 degrees Fahrenheit, which is in compliance with the Title 22 Regulation, 87555 - General Food Service Requirements section. LPA took a picture of the temperature sensor which shows a -5 degrees F. Therefore, based on interviews, record reviews and observations, this allegation is Unsubstantiated.
Regarding the allegation: Due to water leakage there were molds on the floors and walls.
It has been alleged that on August 27. 2024 the facility had a water leak which allegedly resulted to the floors and walls having mold. To investigate this complaint, On 1/2/2025 at 11:00am, LPA conducted an initial complaint visit, LPA toured the physical plant, conducted interview with staff members and facility residents between 12:00PM to 4:00PM. LPA requested pertinent documents/records and conducted record reviews between 12:00PM to 4:00PM.
During the initial visit on 1/2/25, LPA observed no molds on the wall or the floors of where the the leak happened and the surrounding area close to the water leak. LPA conducted interviews with five (05) staff members, S1, S2, S3, S4 and S5 and five (05) residents, R1, R2, R3, R4 and R5 and all confirmed that they did not observe any molds on the floor or the walls. Interviews with S1 and S2 revealed that when both staff members assessed the leak, immediate clean up and repair was done. LPA was provided pictures of the repair of the affected areas. Furthermore, on 1/2/25 the maintenance director, (S1) used a moisture meter which can identify areas where there are high moisture levels. LPA observed S1 utilize the moisture meter on all areas affected of the water leak and LPA observed the moisture meter displayed 0% moisture content. Therefore, based on observations, interviews, and record reviews this allegation is Unsubstantiated.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20241227112439

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 NORTHRIDGE	FACILITY NUMBER: 197610025
	VISIT DATE: 02/20/2025

NARRATIVE

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Regarding the allegation: Call buttons in residents rooms and bathrooms are missing.
It has been alleged that two call bells haven't been installed in the shared rooms in Memory Care and some of the bathrooms in Memory Care doesn't have a call bell. To investigate this complaint, On 1/2/2025 at 11:00am, LPA conducted an initial complaint visit, LPA toured the physical plant, conducted interview with staff members and facility residents between 12:00PM to 4:00PM. LPA requested pertinent documents/records and conducted record reviews between 12:00PM to 4:00PM.
During the initial visit on 1/2/2025 LPA conducted an interview with Memory Care Unit staff, S5 and it was revealed that there are a total of 11 rooms that are shared. LPA conducted a physical tour of each of the 11 rooms and LPA observed that each of these shared rooms have one (1) call button in the bedroom area and one (1) call button in the bathroom. All the bathrooms in each of the 11 shared rooms have call buttons. On 2/20/25, LPA's interview with administrator, S7 revealed that residents are provided with a call pendant. S7 also informed LPA that as stated in the facility's program plan for residents in dementia care unit, the facility develops an individual care plan for each resident, there is also a planned activity program to ensure continual observation of each resident and facility staff initiates an hourly check to each resident during night time. Furthermore an invoice was provided to LPA that shows a purchase of waterproof neck/ call pendants provided for the residents to use.
Therefore, based on observations, interviews, and record reviews this allegation is Unsubstantiated.

No deficiency cited during today's visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC9099 (FAS) - (06/04)

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