565802425-3-21-2022-31-AS-KHEN-CCTTSP-20220324145929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 03/18/2022
Date Signed: 03/21/2022 08:36:18 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
03/23/2020 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 31-AS-20200323162113

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: 53	DATE:	03/18/2022
		UNANNOUNCED	TIME BEGAN:	02:09 PM
MET WITH:	Cynthia Garcia		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Facility did not provide adequate staff to meet resident needs
Facility staff did not provide a sanitary environment for residents
Resident requires a higher level of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Kortnie Spitznogel and Cynthia Garcia, Business Office Manager and explained the purpose for the visit is to conclude an investigation initiated on 04/04/2020 by LPA Kelly Dulek. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 03/23/2020, alleging that facility staff did not provide a sanitary environment for residents. LPA Ascencio conducted interviews on 10/21/21 and 10/26/21 with residents and staff. Resident interviews revealed that facility housekeeping comes into the resident rooms to clean the rooms, bathrooms, sweeps and mop at least one (1) time per week. During an interview in resident #1’s (R1) room on 10/26/21, LPA observed a dirty and sticky floor and little bits of paper on the floor. When questioning R1 regarding their room not being clean, R1 responded with “staff was just in my room to clean it. They just left. I don’t know why it is sticky and dirty.”
Continues on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

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-20200323162113

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: 03/18/2022

NARRATIVE

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The LPA informed Admin of LPA’s observation. Admin proceeded to call housekeeping and clean the room again. The LPA’s observation throughout the facility and other residents’ rooms revealed a clean and sanitary environment for residents. Based on observation and interviews, the allegation is unsubstantiated at this time.

The complaint also alleged that resident requires a higher level of care. During the course of the investigation, LPA Ascencio conducted interviews with staff, residents, responsible parties, and outside agencies on 10/20/2020, 12/10/2020, 08/12/2021 and 10/06/2021. On 10/06/2021, LPA also reviewed facility files and obtained pertinent documents. Interviews stated that resident #2 (R2) had a fall on or around 03/23/2020. File review and interviews on 10/06/2021 confirmed R1 was receiving hospice services before the fall. R2 had a hospice diagnosis of Alzheimer’s Disease unspecified. R2 was regularly monitored and seen by a hospice nurse 2-3 times a week. Interview with R2 could not be conducted as they passed on 09/20/2020. On 08/12/2021, LPA obtained photographs of R2 from facility file between the dates of 03/23/2020 and 03/30/2020, which revealed puffiness and yellow, green, red and purple discoloration on the right side of the face above and below eye. Review of R2’s facility file and chart notes revealed that following the fall, R2 was placed on hourly checks and was given as needed medication for pain management. Review of R2’s hospice notes on 10/06/2021 confirmed R2’s fall on 03/21/2020 and hospice visit on day of and days following of fall. Hospice note on 03/30/2020 states that “R2 continues to walk with eyes closed and needs constant redirection.” Based on interviews and file reviews, the allegation is unsubstantiated at this time.

It was also alleged that facility did not provide adequate staff to meet residents' needs. During the course of the investigations, LPA Ascencio conducted staff interviews on 10/21/21 and 10/26/21. During the interviews, it was revealed that in the morning (am) and evening (pm) shifts, there is a total of three (3) staff members always present. During the night (noc) shift, the facility is staffed with two (2) staff members. Further interviews revealed that there are times that the facility only has two (2) staff members, but the medication tech helps out as caregivers. During resident interviews on 10/21/21 and 10/26/21, it was revealed that when a resident pushes their pendant, the wait time can take between 10-20 minutes before they receive help from a staff. Although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated at this time.

Exit interview conducted. Copy of the report provided via email to Admin

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

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