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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 10/27/2020
Date Signed: 10/28/2020 11:46:46 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2019 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20190814104943
FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:MAHLER, KENNETHFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 64DATE:
10/27/2020
UNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Sara GutierrezTIME COMPLETED:
03:41 PM
ALLEGATION(S):
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Facility staff left resident(s) soiled for an extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a complaint investigation telephonically with Staff Sara Gutierrez who is authorized to review and sign reports due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

The Department received a complaint on 8/14/19, regarding concerns that facility staff left residents soiled for an extended period of time. Interviews with staff #7 (S7), S8 and S15 on 9/27/19 starting at 1:50 pm and S20 on 10/3/19 at 11:17 am revealed that when they came on shift they found a resident that was left in a soiled diaper. An interview with S10 on 9/27/19 at 9:47 am, also revealed that they observed residents in soiled diapers. When care staff were notified, it took an hour for the staff to respond. An interview with Resident #3 (R3) on 9/27/19 at 12:53 pm revealed that they pressed their call button for assistance with changing their family member’s diaper, but staff did not respond to their calls. In addition, an interview with a hospice aide on 9/27/19 at 1:35 pm uncovered an issue that occurred in April 2019, in which their residents were being
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
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 5
Control Number 31-AS-20190814104943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 OXNARD
FACILITY NUMBER: 565802425
VISIT DATE: 10/27/2020
NARRATIVE
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left in soiled diapers for an extended amount of time. Based on the information obtained during the course of this investigation, the complaint allegation is deemed substantiated at this time.

A telephonic exit interview was conducted with Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20190814104943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 OXNARD
FACILITY NUMBER: 565802425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2020
Section Cited
CCR
87625(b)(3)
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Managed Incontinence(b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence..

This requirement is not met as evidenced by:
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Staff stated that they will develop a plan to ensure incontinent residents are changed timely, which will also include staff training on how they will ensure residents are kept clean and soil free.
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Based on interviews, the licensee did not comply with the section cited above as residents were observed to be left soiled for an extended period of time which poses a potential health and personal rights risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2019 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20190814104943

FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:MAHLER, KENNETHFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 64DATE:
10/27/2020
UNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Sara GutierrezTIME COMPLETED:
03:41 PM
ALLEGATION(S):
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9
Facility staff failed to treat residents with dignity and respect
Facility staff failed to prevent residents’ feet from dragging on the floor while using wheelchairs
Facility failed to have an adequate stock of care supplies readily available
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a complaint investigation telephonically with Staff Sara Gutierrez who is authorized to review and sign reports due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

On 8/14/19, the Department received a complaint, regarding a concern that facility staff were not treating residents with dignity and respect, as staff were talking on their personal cells phones and not looking at residents when speaking with them. An interview with resident #4 (R4) on 8/21/19 at 10:31 am revealed that they have not observed staff talking on their cell phones during their shifts. Interviews with staff #1 (S1) and S6 on 8/21/19 starting at 10:17 am and S16 and S17 on 9/27/19 starting at 11:39 am also revealed that they have not observed staff talking on their cell phones. The complainant additionally alleged that facility staff

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20190814104943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 OXNARD
FACILITY NUMBER: 565802425
VISIT DATE: 10/27/2020
NARRATIVE
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failed to prevent residents’ feet from dragging on the floor while using wheelchairs. Interviews with R3, R7, R8, R9, R10, S5, S7, S8, S9, S10, S11, S12, S13, S15, S16, S17 on 9/27/19 starting at 9:39 am, concluded that no one has observed staff dragging residents’ feet while using wheelchairs.
Lastly, the complainant also alleged the facility failed to have an adequate stock of care supplies (depends, gloves and trash bags) readily available. Interviews with S7, S14 on 9/27/19 starting at 1:50 pm and S18 on 11/22/19 at 9:25 am revealed that the facility keeps supplies of bags and gloves and resident’s family/hospice provide diapers for residents. Interviews with S8 and S17 on 9/27/19 starting at 12:13 pm and S20 on 10/3/19 starting at 11:17 am revealed that the facility is stocked with gloves and bags. An interview with S19 on 11/22/19 at 9:29 am revealed that they maintain supplies of gloves and bags and reorder when needed. During facility tours on both 9/27/19 and 11/22/19, LPA observed a sufficient supply of gloves and bags. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the above complaint allegations and are therefore deemed unsubstantiated at this time.

A telephonic exit interview was conducted with Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5