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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 03/25/2022
Date Signed: 03/25/2022 05:22:41 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2020 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200519123141
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: 55DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Matthew Girardot, Sales DirectorTIME COMPLETED:
04:57 PM
ALLEGATION(S):
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Staff isolating residents from authorized representatives while in care
Staff emotionally abuses residents while in care
Staff creates fictitious medical reasons for residents without authorization
Staff mishandles resident while in care
Staff retaliates against residents while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 01:47PM to conduct a subsequent complaint investigation, with the purpose of delivering findings for the allegations listed above. LPA met with facility Sales Director Matthew Girardot. Facility Executive Director was not available during today’s visit. Entrance interview conducted.

During today's visit, LPA, along with Sales Director Matthew Girardot, toured the facility at 01:55PM. Previously, on 05/27/2020, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, LPA conducted the initial visit telephonically with Executive Director Ken Mahler at 12:15PM. LPA Dulek conducted a telephone interview with the administrator at 12:18PM, requested documents via email, and conducuted a medication audit via FaceTime with the med tech at 3:43PM. LPA then reviewed the documents recieved, conducted telephone interviews with staff and residents. The following was then determined: REPORT CONTINUED ON LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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 6
Control Number 29-AS-20200519123141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: PACIFICA SENIOR LIVING OXNARD
FACILITY NUMBER: 565802425
VISIT DATE: 03/25/2022
NARRATIVE
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LPA Dulek spoke with relevant parties, including R1's family members, complainant, R1, R2, as well as facility staff and Administrator. Additionally, LPA reviewed a staff roster provided by the facility. LPA then determined the individual named by the complainant was not currently nor had the individual ever been employed by the facility. The individual in question was employed by R1's family as a private duty aide for R1. This individual never worked for the facility, and therefore does not qualify as facility staff. Therefore, based on interview and record review, the allegations that "Staff isolating residents from authorized representatives while in care," "Staff emotionally abuses residents while in care," "Staff creates fictitious medical reasons for residents without authorization," "Staff mishandles resident while in care," and "Staff retaliates against residents while in care" are deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of the report was provided via email.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2020 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200519123141

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: 55DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Matthew Girardot, Sales DirectorTIME COMPLETED:
04:57 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff mishandling resident's medication
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 01:47PM to conduct a subsequent complaint investigation, with the purpose of delivering findings for the allegations listed above. LPA met with facility Sales Director Matthew Girardot. Facility Executive Director was not available during today’s visit. Entrance interview conducted.

During today's visit, LPA, along with Sales Director Matthew Girardot, toured the facility at 01:55PM. Previously, on 05/27/2020, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA conducted the initial visit telephonically with Executive Director Ken Mahler at 12:15PM. LPA Dulek conducted a telephone interview with the administrator at 12:18PM, requested documents via email, and concuted a medication audit via FaceTime with the med tech at 3:43PM. LPA then reviewed the documents recieved, conducted telephone interviews with staff and residents. The following was then determined: REPORT CONTINUED ON LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20200519123141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: PACIFICA SENIOR LIVING OXNARD
FACILITY NUMBER: 565802425
VISIT DATE: 03/25/2022
NARRATIVE
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During the subsequent complaint visit conducted on 05/27/2020, LPA Dulek conducted FaceTime video call to conduct a medication audit for Resident #1 (R1) and review of Resident #2 (R2)’s medication at 3:43PM. LPA observed that although Staff #1 (S1) stated that R1’s routine medication Atropine was discontinued as of Friday 5/22/2020, documentation on the MAR reflects the medication was administered at 5:00PM on 5/26/2020. S1 indicated this is an error on the electronic MAR, but there is handwritten documentation of the error. Handwritten documentation was unable to be provided to the LPA upon request. Additionally, R1’s Senna-Docusate was not initialed as administered on 5/13/2020 and 5/16/2020. Further review of the MAR pass notes indicates that on 5/14, 5/15, 5/18, 5/19, 5/20, and 5/21/2020 “waiting for med delivery.” Staff #1 (S1) indicated that the new pack of R1’s Senna Docusate was started on 5/20/2020 and LPA observed 21 pills remaining in the bubble pack. LPA Dulek requested a copy of the physician’s orders to discontinue R1’s daily Atropine and a copy of the medication destruction record for the Atropine. The LPA also requested a copy of the documentation indicating the electronic MAR error for R1’s Atropine on 5/26/2020. Administrator agreed to email all requested documentation by the end of business on 5/27/2020. Documentation was later discussed with the facility Executive Director, but no additional documentation was received. Therefore, based on record review and observation, the allegation that "Staff mishandling resident's medication" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D)
Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were issued via email.
SUPERVISOR'S NAME: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20200519123141
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: PACIFICA SENIOR LIVING OXNARD
FACILITY NUMBER: 565802425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2022
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Licensee will provide vendorized medication training to all staff who assist with medication and provide proof, to include signed roster of attendees, name and credentials of trainer, date of training, and training agenda to CCL by 04/08/2022.
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Based on medication review, the facility did not assist R1 with their medications as prescribed, as medications were waiting for refill and unable to be administered, as well as discontinued medication was marked as administered, which poses an immediate health and safety risk for residents 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: TELEPHONE:
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE:
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6