<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 03/25/2022
Date Signed: 03/25/2022 05:21:02 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
11/25/2020 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20201125144906
FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:MARKOVICH, PAULFACILITY 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
4
5
6
7
8
9
Resident sustained bed sore while in care
Resident not administered medication as prescribed
Staff left resident in soiled clothing for extended period of time
Facility staff not responding to resident's call button
Facility staff not safeguarding resident’s property
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
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. No health and safety hazards were observed during today's tour. Previously, on 12/04/2020, between 4:22 p.m. and 5:05 p.m., LPA Dulek conducted an 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 facility designee Sara Gutierrez. The LPA conducted an interview and physical plant tour with the Resident Care Director at 4:25 p.m. The LPA requested copies of pertinent documents relevant to the investigation and noted further investigation would be required. During the course 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: 1 of 6
Control Number 29-AS-20201125144906
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
of the investigation, staff and resident interviews were conducted both in person at the facility as well as over the telephone on the following dates: 08/24/2020, 08/25/2020, 12/14/2020, 12/17/2020, 05/26/2021, and 10/21/2021. The following was then determined:

Regarding the allegation “Resident sustained bed sore while in care:
Resident #1 (R1) moved into the facility on 06/01/2020. Resident’s paperwork filled out upon admission was reviewed and did not contain any indication of existing wounds upon admission to the facility. Interview with R1’s family member confirmed R1 had no pressure injuries prior to residing at the facility. Care notes reviewed did not indicate any wounds on R1’s body. The resident was admitted to hospice on 08/20/2020, at which point a Stage 2 wound was noted on R1’s coccyx, as well as skin tears on R1’s legs and both arms. Photographs of the wounds were provided to the LPA. Staff interviews revealed that R1’s pressure injuries were “real deep” and a “real bad wound.” Former administrator indicated they were unaware the resident had any wounds until R1 was admitted to hospice. Therefore, based on interview and record review, the allegation that “resident sustained bed sore while in care” is deemed SUBSTANTIATED at this time.

Regarding the allegation “Resident not administered medication as prescribed:
LPA reviewed R1’s medication administration record as well as care notes. Two times in June, on both the 26th and 27th, it was noted that R1 was unable to receive medications as prescribed, as the medications had not yet been refilled. Medication records reviewed indicated PRN acetaminophen was administered only one time in the month of August 2020 and PRN morphine was administered on 3 dates in August 2020. Interview with former Administrator revealed that the facility did not have a PRN authorization on file for R1. Therefore, based on interview and record review, the allegation that “resident not administered medication as prescribed” is deemed SUBSTANTIATED at this time.

Regarding the allegation “Resident left in soiled clothing for extended period of time:"
Review of R1’s Needs and Service Appraisal indicated that R1 requires assistance with ADLs including toileting assistance, dressing, bathing, and grooming. Interview revealed that on 08/24/2020, R1 was observed to have urine leaking from their pants and noted to be soiled in urine and feces. Staff interview indicated R1 had not been changed for some time, which resulted in the soiled clothing. The exact amount of time the resident was left in soiled clothing is unknown, however the feces was noted to be dried under the
Report Continued on LIC 9099-C
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: 2 of 6
Control Number 29-AS-20201125144906
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
resident’s nails and on the resident’s clothing. Therefore, based on interview, the allegation “resident left in soiled clothing for extended period of time” is deemed SUBSTANTIATED at this time.

Regarding the allegation “Facility staff not responding to resident’s call button:”

Interview with a witness revealed that on 08/24/2020, the witness pressed the resident’s pendant while in R1’s room. The witness waited for over 30 minutes for a response and only received a response when using the telephone to call for assistance. R1’s call button was replaced that same day. However, the following day, on 08/25/2020, R1’s visitor pressed the pendant and again received no response for approximately 30 minutes. Staff interview revealed that according to facility policy, care staff should respond to a resident’s request for assistance within 2 alerts on the call system, which equates to 10 minutes or less. 6 (six) of 6 (six) residents interviewed all stated that call times vary, but all have had to wait upwards or 20 minutes to an hour for a response. SMARTCare records reviewed for a one-week period indicated a wait time or greater than 10 minutes for 175 calls during a one-week period. Additionally, during that same one-week period, there was no response to the call button at all 65 times. Therefore, based on record review and interview, the allegation “facility staff not responding to the resident’s call button” is deemed SUBSTANTIATED at this time.

Regarding the allegation “Facility staff not safeguarding resident’s property:”

Interviews conducted during the course of the investigation revealed that medical supplies were left in the resident’s room as of 08/22/2020. Those supplies were unable to be located as of 08/24/2020. Staff interview revealed that “caregivers take patient supplies for use on other patients” and Administrator added that “things should not be left in patients’ rooms because they have been found to go missing.” In addition to medical supplies missing, R1's family left an electronic item for R1 which was also unable to be located. Based on interview, the allegation that “facility staff not safeguarding resident’s property” is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D.)
The Sales Director was informed that civil penalties may be assessed at a later date based on Health and Safety Code 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report was 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-20201125144906
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
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 03/28/2022.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the section cited above, as the licensee failed to provide adequate care and supervision to R1 which contributed to R1 sustaining pressure injuries and R1's clothing observed with dried fecal matter, which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
03/28/2022
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...appropriate supervision is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented...
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 03/28/2022.
8
9
10
11
12
13
14
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 contributed 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: 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: 4 of 6
Control Number 29-AS-20201125144906
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(d)(1)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (d) If the resident is unable to determine...PRN medication and is unable to communicate his/her symptoms clearly...shall be permitted to assist the resident with self-administration provided (1) Facilty staff...dose of medication.
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 residents in need of PRN medications who cannot verbally communicate their needs to ensure resident needs are met. Submit to CCL by 03/28/2022.
8
9
10
11
12
13
14
Based on interviews and records review, 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.
8
9
10
11
12
13
14
Type B
04/08/2022
Section Cited
CCR
87303(i)(1)(A)
1
2
3
4
5
6
7
87303 Maintenance and Operation. (i)Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more...floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit.
This requirement is not met as evidenced by:
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 04/08/2022.
8
9
10
11
12
13
14
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 August 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: 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
Control Number 29-AS-20201125144906
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 B
04/08/2022
Section Cited
CCR
87217(b)
1
2
3
4
5
6
7
87217 Safeguards for Resident Cash, Personal Property, and Valuables (b)Every facility shall take appropriate measures to safeguard residents'...personal property... which have been entrusted to the licensee or facility staff...articles or cash resources.
This requirement is not met as evidenced by:
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 04/08/2022.
8
9
10
11
12
13
14
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
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: 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: 6 of 6