565802425-3-21-2022-29-AS-KHEN-CDHW47-20220415165703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 03/18/2022
Date Signed: 03/21/2022 08:44:04 AM

Unsubstantiated

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
05/07/2020 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20200507130645

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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Resident is left in soiled diapers for extended periods of time
Staff did not give medication to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegations initiated by LPA Brian Basili on 05/02/2020. LPA Ascencio met with Administrator Kortnie Spitznogle and Cynthia Garcia, Business Manager at 2:09 p.m. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 05/12/2020, alleging that resident is left in soiled diapers for extended periods of time and that staff did not give medication to resident. Interviews with residents on 10/21/21, 10/26/21 and 12/13/21 revealed that the staff help assist residents to use the restroom when the resident push their pendant. Interviews further revealed that it is on rare occasions that residents have to wait for staff to help them out. Interview with Resident #1 could not be conducted as resident no longer resides in facility. Interviews with staff on 10/21/21 revealed that staff check in resident about three (3) times a day or about every two (2) hours during their shift. Resident push their pendent, the staff respond to it as soon as possible by walking to the resident apartment and assisting them.
Continued 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 29-AS-20200507130645

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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Further interviews revealed that the majority of resident don’t require as much help but those that do, are kept in a two (2) hour check in or as needed for toileting needs. Interview with previous Administrator stated that R1 had a machine in their room and did not know how to use it. Admin also said that R1 needed additional help but Family Member #1 (FM1) didn’t want to pay extra or have R1 on hospice services. Because R1 needed additional help, Admin wanted to move R1 to Memory Care but FM1 did not want to pay for those services. R1 was also not incontinence. Our staff helped R1 with stand-by toileting assistance. R1 would administer their own medication because the FM1 didn’t want to pay for a higher level of medication management. Admin added, R1 needed a higher level of med management because R1 didn’t know how to use the machine in their room. R1’s Physician Report dated 05/30/2019 indicates that R1 is able to administer own prescription medication, able to administer own PRN medication, and able to store own medication. The report also states that R1 can transfer independently from the bed, is non-ambulatory, does not have bowel or bladder impairment, and is able to care for own toileting needs. LPA also reviewed R1’s Preplacement Appraisal Information and revealed that R1 needs assistance with bathing, hair care, personal hygiene, and does not need assistance with toileting or incontinence control. LPA reviewed R1’s Needs and Services Plan signed and dated on 05/06/2020 revealed that R1 needed total assistance with bathing, and dressing, stand-by assist with transfers and toileting, and self administer of own medication. Interview with FM#1 on 05/12/2020 starting at around 11:00 am, revealed that R1 would tell FM1 that the staff don’t change R1’s diapers. FM1 also added that they would arrive at the facility to visit R1 and would find them in soiled diapers. Regarding medication, FM1 added that R1 had a medication machine in their room that dispensed medication. FM1 added there was one instance that FM1 dropped of medication for R1, staff was confused since the facility doesn’t help R1 with medication. FM1 personally went to R1’s room to refill the machine. LPA reviewed R1’s chart notes and a Narrative Chart note entry dated on 05/06/2020 stated “ Followed up with FM1. FM1 placed antibiotics in the machine. FM1 was called at 3:22 pm.”

Although the allegations may have happened, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegations are unsubstantiated at this time.

Exit interview conducted. Copy of the report was provided to Admin and Business Office Manager via email.

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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