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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 10/26/2021
Date Signed: 10/26/2021 07:46:58 PM

Substantiated


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 OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:MAHLER, KENNETHFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 48DATE:
10/26/2021
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff are not responding to residents calls for assistance in a timely manor
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to continue investigation. LPA met with Executive Director Kortnie Spitznogle at 10:30 a.m. Entrance interview conducted.

It was alleged that staff are not responding to residents call for assistance in a timely manner. Interviews with staff #1 (S1), S2, S3 and S4 on 10/21/21 starting at 12:33 p.m. revealed that all residents in the assisted living side have a call button with them. When residents need help, they push the button alerting staff member on their pagers. Once a call button is pressed, staff head to the room as soon as possible or call for help, shut off the alert button with their own button they have, then help out resident in need. Further interviews revealed that the staff need to respond before the 3rd call on their pager.

Continued on LIC-9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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 4
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: 10/26/2021
NARRATIVE
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LPA reviewed the facilities procedures and policy at it pertains to call response and it states at the bottom in handwritten black ink, “Note: 15 min response time. Do not forget to reset!! Time is crucial!!”. LPA could not find anything else regarding response time.

Interviews with resident #1, (R1), and R2 on 10/21/21 starting at 2:55 p.m. and further interviews with R3, R4, R5, R6, R7 and R8 on 10/26/21 starting at 11:05 a.m revealed that wait times for staff can take a bit longer than normal with residents waiting for about 20-30 minutes. Some days, caregiver response can take more time like 30-45 minutes. There have been other occasion of residents waiting up to one (1) hour for staff to come by and help. On 10/21/21, LPA obtained SMARTcare logs for the last week of April 2020, all month of May 2020 and first week of June 2020. On 10/26/2021 at 1:00 p.m. it was revealed from the SMARTcare logs that a total of five hundred and seventy-seven (577) call buttons have elapsed passing the fifteen (15) minutes mark. There have also been three-hundred and seventy-one (371) calls that have not been responded to.

Based on interviews and evidence gathered throughout the investigation, the allegation staff are not responding to residents call for assistance in a timely manner is substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of


Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in
civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email to the executive director.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/12/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Admin will provide training on Personal Rights and Process and Procedure on the call monitoring system for time effeciency to staff. Admin will provide copy of training material and staff attendees to LPA via email.

angel.ascencio@dss.ca.gov
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Based on record review, interviewsand observations the licensee did not comly with teh section cited above as the facility did not not responding to residents calls for assistance in a timely manor.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC9099 (FAS) - (06/04)
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