565802425-3-18-2022-29-AS-KHEN-CCXR6X-20220328124528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 03/18/2022
Date Signed: 03/18/2022 04:57:38 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2020 and conducted by Evaluator Teresa Camara

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200902093912

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:	12:10 PM
MET WITH:	Cynthia Garcia		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Neglect/Lack of Supervision: Resident #1 (R1) sustained multiple pressure injuries while in care
Neglect/Lack of Supervisiion: Facility staff did not seek medical attention for Resident #1 (R1)
Staff mismanaging resident’s medication
Staff not responding to resident’s call button in a timely manner
Resident was left in soiled diaper for extended period of time
Staff not providing adequate food service to resident
Staff did not safeguard personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit on 03/18/2022 to deliver final findings for the above allegations. The initial visit was conducted on 09/02/2020 by LPA Kelly Dulek and subsequent visits were conducted on 11/4/2021 and 03/15/2022 by LPA Camara. During today’s visit, Administrator Kortnie Spitznogle left the facility to pick up a resident so LPA met with Business Office Manager Cynthia Garcia and explained the reason for the visit.

On 09/02/2020, the Department received a complaint regarding allegations of Neglect/Lack of Supervision. It was alleged that former Resident #1 (R1) sustained multiple pressure injuries while in care and facility staff did not seek medical attention for R1. It was reported that the pressure injuries were not discovered until the hospice care intake on 08/20/2020. The complaint was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson.

(continued on page 2; 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
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)

Page: 1 of 11

Control Number 29-AS-20200902093912

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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(continued from page 1; 9099)

On 09/02/2020, between 4:47 p.m. and 6:40 p.m., LPA Dulek conducted the initial complaint visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with Resident Care Director Sara Gutierrez. The LPA conducted an interview and physical plant tour with the Resident Care Director at 5:27 p.m. and reviewed the pendant/resident call system at 5:36 p.m. The LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required.

On 11/04/2021, LPA Camara conducted an unannounced subsequent complaint visit. LPA met with Administrator/Executive Director Kortnie Spitznogle and Resident Care Director Marta Tapia and explained the reason for the visit. During the visit LPA conducted a brief physical plant tour at 12:53 p.m., interviewed staff starting at 1:20 p.m., interviewed residents starting at 2:25 p.m., reviewed records at 3:58 p.m. and noted further investigation was required.

Investigator Patterson conducted interviews with R1’s representative on 10/21/2020, at approximately 4:16 p.m. and on 11/09/2020, at approximately 3:33 p.m.; with the Long Term Care Ombudsman (LTCO) on 11/11/2020, at approximately 2:17 p.m.; with TLC Hospice on 12/10/2020, at approximately 4:42 p.m.; with facility staff on 12/14/2020, from approximately 2:35 p.m. to 3:48 p.m.; and with Facility Administrator Sara Gutierrez on 12/17/2020, at approximately 9:10 a.m. Additionally, Investigator Patterson obtained and reviewed copies of facility records, hospice records and photographs of wounds/pressure injuries related to R1.

Information gathered reflected R1 was admitted to the facility on 06/01/2020. At that time R1 was ambulatory and able to articulate their needs in spite of having had a stroke and showing signs and symptoms of dementia. R1’s medical history included depression, frequent urinary tract infections, heart disease, stroke, and dysphagia. The narrative charting record for R1 indicated on 07/25/2020, R1 was found by a caregiver sitting on the floor in the middle of their living room. R1 was noted to becoming weaker and in need of total assistance with toileting and feeding. On 08/02/2020, R1’s Doctor was contacted to obtain authorization for

(continued on page 3; 9099-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
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)

Page: 2 of 11

Control Number 29-AS-20200902093912

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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(continued from page 2; 9099-C)

medical assistance as R1 “seemed a lot weaker” and in need of “a lot” more assistance. On 08/15/2020, R1’s representative came and bandaged R1’s legs due to R1’s itching and scratching, which caused bleeding. Band-aids were placed on R1’s arms; however, R1 took them off twice and R1’s representative was notified. R1’s representative was not informed by facility staff until approximately 08/15/2020, that R1 had not been ambulating on R1’s own in over a few weeks. On 08/20/2020, R1 was assessed and admitted to TLC Hospice Care due to Alzheimer’s disease and rapid decline in health. During the hospice assessment, R1 was observed to have a large stage 1 area to the coccyx with multiple scabs, and stage 2 areas within; large skin tear to left lower leg; and multiple open sores to both forearms. The assessment also noted that since being admitted to the facility, R1 had rapidly declined, required support with all activities of daily living, and was in severe discomfort and significant pain. Information gathered further revealed that it was not until the hospice care was initiated that R1’s pressure injuries and wounds were diagnosed, treated and reported to R1’s representative.

On the allegation: Neglect/Lack of Supervision: Resident #1 (R1) sustained multiple pressure injuries while in care. The Residential Care Director stated she was never made aware that R1 had a pressure injury or scattered skin tears until R1 was accepted into hospice care. She admitted that the facility staff’s lack of documentation and communication, but also failing to provide appropriate supervision and care, attributed to neglecting R1’s change of condition and pressure injury/wound care needs going unmet. Based on records reviewed, interviews conducted, and photographic evidence of R1’s wounds/pressure injuries, neglect/lack of supervision and care was found to have attributed to R1 sustaining pressure injuries which went unreported and not cared for, therefore, the allegation is deemed Substantiated at this time.

On the allegation: Neglect/Lack of Supervision: Facility staff did not seek medical attention for Resident #1 (R1). On 08/20/2020, during the hospice care intake R1 was discovered to have pressure injuries to coccyx area and scattered wounds to arms and legs. It was further reported R1 was in significant pain. Investigator Patterson conducted interviews with the facility staff who reported that the facility does not assess or treat

(continued on page 4; 9099-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
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)

Page: 3 of 11

Control Number 29-AS-20200902093912

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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(continued from page 3; 9099-C)

pressure injuries/wounds other than basic first aid; further pain medication, PRN (as needed) is not provided unless the resident asks for them. Information obtained during witness interviews found that R1 was in severe pain and believed the facility did not provide care, pain medication or did not seek out appropriate medical attention. The Resident Care Director stated once hospice care was implemented for R1, it was not the facility’s responsibility to care for R1’s wounds. She further stated she was never made aware by facility staff that R1 was in pain or had pressure injuries or multiple skin tears which continued to exacerbate while in care. She admitted the facility’s failure to communicate attributed to failing to seek out medical attention. Based on witness statements and documents obtain and reviewed, the allegation is deemed Substantiated at this time.

On the allegation: Staff mismanaging resident's medication: On 12/17/2020, Investigator Lorraine Patterson interviewed administrator Sara Gutierrez who indicated if a resident appears to be in pain but cannot verbalize their need for PRN pain medication, the medication technician should contact the resident's physician for approval to provide the PRN pain medication. R1 had acute pain due to pressure injuries and multiple skin tears. According to witnesses, R1 was in obvious pain. R1's PRN pain medication was delivered to the facility on 08/21/2020. Records show R1 was prescribed two PRN narcotic pain medications which were administered on 08/24,25,27,28,29/2020. According to administrator Sara Gutierrez there was no evidence the facility staff attempted to contact anyone (physician or hospice) over the weekend of 08/22-23/2020 for approval to administer the prescribed PRN pain medications. In addition, a medication technician interviewed by the Investigator confirmed the discovery that R1 went without this pain medication for an entire weekend. Based on the administrator's statement to the Investigator and documentation showing the medication was not administered, the allegation is deemed Substantiated at this time.

On the allegation: Staff not responding to resident’s call button in a timely manner. On 12/17/2020, Investigator Lorraine Patterson requested copies of the call button service alerts for R1 from facility administrator Sara Gutierrez, however these logs were never provided to the Investigator. On 11/4/2021, LPA

(continued on page 5; 9099-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
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)

Page: 4 of 11

Control Number 29-AS-20200902093912

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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(continued from page 4; 9099-C)

Camara requested call button service alert records for the facility from June 2020 through September 2020. LPA was provided logs from 06/04/2020 - 09/27/2020. Upon closer review, LPA noted records were missing from 06/23/2020 through 09/18/2020. During LPA's visit on 03/18/2022, call button records were requested for the month of August 2020. LPA was provided 537 pages of records. There was only one call noted from R1 which occurred on 08/24/2020 at 1:36 p.m.; it was announced to caregivers eight times before someone responded and it took 39 minutes for the caregivers to respond. LPA reviewed the other alert records provided by the facility and noted there were numerous alerts for other residents to which staff never responded or where response times ranged from 28 - 44 minutes. In addition, based on witnesses' accounts who had visited R1 multiple times in August of 2020, staff would not respond when R1's call button was pushed and the visitors would have to locate staff by calling the main phone number. On 08/24/2020 a caregiver brought a new call button to R1 as it seemed the one R1 had was not working. Based on witness statements, this allegation is deemed Substantiated at this time.

On the allegation: Resident was left in soiled diaper for extended period of time: On 08/24/2020 a witness observed R1 was sitting for an extended period in a soiled diaper (soaked in urine, urine leaked out of diaper, and the diaper was smeared with feces). The witness also pointed out R1's call button seemed inoperable. The caregiver brought a new call button and told the witness to speak with the next caregiver coming on shift about any other concerns. Other witnesses interviewed had observed R1 was left in soiled diapers for extended periods as well as feces under R1's fingernails. Based on witness statements, this allegation is deemed Substantiated at this time.

On the allegation: Staff not providing adequate food service to resident: LPA Camara interviewed residents and staff on 11/04/2021. During the COVID-19 outbreaks at the facility all residents were served meals in their room due to isolation protocols set forth by the Department of Public Health. During that time period the facility lost nearly all of their cooks. Other facility staff, including management, helped with cooking while the facility searched to hire new cooks. They offered menu items suggested by their corporate office, they were taught how to make the menu items and they offered alternative menu items. However, residents who were

(continued on page 6; 9099-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
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)

Page: 5 of 11

Control Number 29-AS-20200902093912

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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(continued from page 5; 9099-C)

interviewed indicated there was a short period of time when all they received were sandwiches. In addition, residents indicated that some of the food they received was cold when it should have been hot. One caregiver indicated that was a possibility depending on where the resident's room was located as they may have been served last. Based on interviews with staff and residents, this allegation is deemed Substantiated at this time.

On the allegation: Staff did not safeguard personal belongings: Based on witness interviews by Investigator Lorraine Patterson, one witness discovered on 08/24/2020 R1's personal care supplies, which had been left in R1's room, were missing. The witness reported the missing items to administrator Sara Gutierrez who told the witness things should not be left in residents' rooms because things go missing. The witness was told by a medication technician that caregivers tend take such supplies for use on other residents. In addition, R1's family left an electronic item for R1 which was also missing. Based on witness statements, this allegation is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Business Office Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)
Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
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)

Page: 6 of 11

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
09/02/2020 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20200902093912

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:	12:10 PM
MET WITH:	Kortnie Spitznogle		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Resident’s are not provided with daily activities

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit on 03/18/2022 to deliver final findings for the above allegations. The initial visit was conducted on 09/02/2020 by LPA Kelly Dulek and subsequent visits were conducted on 11/4/2021 and 03/15/2022 by LPA Camara. During today’s visit, Administrator Kortnie Spitznogle left the facility to pick up a resident so LPA met with Business Office Manager Cynthia Garcia and explained the reason for the visit.

Beginning on approximately 07/16/2020, the facility experienced COVID-19 outbreaks throughout the remainder of the year and into January of 2021. During that time, under orders of Department of Public Health, the facility had to cancel group activities and communal dining. Residents who were interviewed confirmed that prior to the outbreaks the facility offered activities. When given clearance by Public Health the facility resumed group activities and communcal dining. Based on the Public Health order to isolate residents due to a COVID-19 outbreak, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
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)

Page: 7 of 11

Control Number 29-AS-20200902093912

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: 03/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/25/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented and	1 2 3 4 5 6 7	LIcensee will submit a plan to provide proper observation of residents and communication of changes of in condition to ensure residents' needs are met. Plan must be submitted to CCL on or before 03/25/2022.
	8 9 10 11 12 13 14	brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The facility failed to observe, document and communicate R1's pressure injuries/wounds which attributed to	8 9 10 11 12 13 14	failing to seek out medical attention for R1, which posed an immediate health and safety risk to residents in care.
Type A 03/25/2022 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by:	1 2 3 4 5 6 7	LIcensee will submit a plan to provide proper level of care and supervision to ensure residents' needs are met. Plan must be submitted to CCL on or before 03/25/2022.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above. Licensee failed to provide adequate care and supervision to R1 which attributed to R1 sustaining pressure injuries not reported and not cared for, which posed an immediate health and safety risk to residents 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 11

Control Number 29-AS-20200902093912

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: 03/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/25/2022 Section Cited CCR 87465(d)(1)	1 2 3 4 5 6 7	87465(d)(1) Incidental Medical and Dental Care. If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided	1 2 3 4 5 6 7	Licensee will submit a plan to provide proper level of care and supervision to residents in need of PRN medications who cannot verbally communicate their needs to ensure resident needs are met. Submit to CCL by 3/25/2022.
	8 9 10 11 12 13 14	all of the following requirements are met: Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. This requirement is not met as evidenced by: Based on interviews and records review	8 9 10 11 12 13 14	R1 was in obvious pain, however staff failed to contact hospice or a physician for authorization to administer any PRN pain medication 8/21/20-8/23/20, which posed an immediate health and safety risk to residents in care.
Type B 03/25/2022 Section Cited CCR 87303(i)(1)(A)	1 2 3 4 5 6 7	87303(i)(1)(A) Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Operate from each resident's living unit.	1 2 3 4 5 6 7	Licensee will submit a plan to conduct testing on the call buttons to ensure they are all functioning properly and provide staff training regarding call button alert response times. Submit to CCL by 3/25/2022.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and record review, R1's call button was not working on 8/24/2020. In addition, other call button alerts went unresponded for other residents during the period of June 2020 - September 2020, which poses a potential health and safety risk to residents 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 9 of 11

Control Number 29-AS-20200902093912

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: 03/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/25/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their	1 2 3 4 5 6 7	Licensee will submit a plan to conduct testing on the call buttons to ensure they are all functioning properly and provide staff training regarding call button alert response time expectations. Submit to CCL by 3/25/2022.
	8 9 10 11 12 13 14	individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and record review of alert response times, some responses were not completed in a timely manner and otehr calls went unanswered, which posed a potential	8 9 10 11 12 13 14	health and safety risk to residents in care.
Type B 03/25/2022 Section Cited CCR 87217(b)	1 2 3 4 5 6 7	87217(b) Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or	1 2 3 4 5 6 7	Licensee will submit a plan to properly safeguard residents' property as well as provide staff training regarding safeguarding residents' personal property. Submit to CCL by 3/25/2022.
	8 9 10 11 12 13 14	cash resources.This requirement is not met as evidenced by: Based on interviews with witnesses, R1 was missing personal care items that had been left by a skilled nursing professional, as well as a remote left by family, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 10 of 11

Control Number 29-AS-20200902093912

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: 03/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/25/2022 Section Cited CCR 8755(a)	1 2 3 4 5 6 7	8755(a) General Food Service Requirements. (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and	1 2 3 4 5 6 7	Licensee will submit a plan for future instances where all residents must receive tray service due to an isolation order. The plan should describe how licensee will ensure all residents are served quality food that is safe and healthful. Submit to CCL by 3/25/2022.
	8 9 10 11 12 13 14	healthful manner. This requirement was not met as evidenced by: Based on interviews, while tray service was being provided to all residents due to COVID-19, some residents were receiving cold food which should have been served hot, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC9099 (FAS) - (06/04)

Page: 11 of 11