565802425-11-6-2020-31-AS-KHEN-BVT5Y3-20201128192134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 08/21/2019
Date Signed: 11/06/2020 04:02:00 PM

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., STE. 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 OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	MAHLER, KENNETH		FACILITY TYPE:	740
ADDRESS:	2211 E GONZALES RD		TELEPHONE:	(805) 983-6808
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	100	CENSUS: 84	DATE:	08/21/2019
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Sara Gutierrez		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Facility staff failed to ensure residents were appropriately dressed (not wearing shoes while walking)
Insufficient staffing

INVESTIGATION FINDINGS:

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**This is an amended report to add a deficiency to the LIC809-D report**
During today's visit Licensing Program Analyst (LPA) JoAnn Rosales toured the facility, interviewed residents and staff.

Concerns were that the facility staff failed to ensure residents were appropriately dressed (not wearing shoes while walking). During facility tour on 8/21/19 at 10:13 am LPA observed resident # 1 (R1) walking in the dining room without shoes in socks pushing around a dining chair. LPA also observed R1's pants wet on the backside area due to sitting on a wet outside patio chair. LPA alerted the medication technician staff #1 (S1) who indicated that they will let the caregiver know. Concerns were that the facility was not sufficiently staffed. During the facility tour on 8/21/19 at 10:13 am LPA observed one caregiver in the dining room with residents while the other caregiver was on their lunch break. Interview with S1 revealed that they do not provide

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020

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

LIC9099 (FAS) - (06/04)

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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING OXNARD	FACILITY NUMBER: 565802425
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/28/2019 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staff stated that they will provide a staff schedule which reflects sufficient staffing to meet resident needs.
	8 9 10 11 12 13 14	Based on LPA's observations and interviews, the licensee failed to ensure that they had sufficient staffing to meet resident needs which posed a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 11/16/2020 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	Basic services(f)(1)(c) "Care and Supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staff stated that they will provide documentation of staff training regarding care and supervision.
	8 9 10 11 12 13 14	Based on LPA's observations, the licensee did not comply with the section cited above as R1 was observed by LPA walking in the dining room without shoes which poses a potential safety risk to persons in care.	8 9 10 11 12 13 14

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020

LIC9099 (FAS) - (06/04)

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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING OXNARD	FACILITY NUMBER: 565802425
	VISIT DATE: 08/21/2019

NARRATIVE

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caregiving assistance as they are a medication technician. Interview with staff #2 (S2) revealed that there are22 residents in the memory care unit. Based on the information gathered during the course of the investigation the allegations are deemed substantiated at this time.

Civil penalties assessed in the amount of $250.00.

Exit interview conducted. Today's reports, civil penalty and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020

LIC9099 (FAS) - (06/04)

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