565802425-4-13-2022-29-AS-KHEN-CDXULX-20220429154127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 04/12/2022
Date Signed: 04/13/2022 08:38:41 AM

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
04/04/2022 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20220404114101

FACILITY NAME:	PACIFICA SENIOR LIVING OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	GUTIERREZ, SARA		FACILITY TYPE:	740
ADDRESS:	2211 E GONZALES RD		TELEPHONE:	(805) 983-6808
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	100	CENSUS: 58	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	02:33 PM
MET WITH:	Kortnie Spitznogle		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Facility failed to handle outbreak appropriately.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted an initial complaint investigation to the above facility. LPA met with Administrator Kortnie Spitznogle at 2:35 p.m. LPA and Admin toured the community at 4:30p.m. Entrance interview conducted.

It is being alleged that facility failed to handle outbreak appropriately. LPA Ascencio received a telephone call on 4/4/22 at approximately 11:33 a.m from Ventura Public Health Registered Nurse (VCPH). VCPH informed LPA they received an anonymous tip that there was an outbreak at the facility, and it had not been reported and that the building is not doing anything about that. On 4/4/22, LPM Kristin Heffernan, LPA JoAnn Rosales and Ascencio received an email from Long-Term Care Ombudsman (LTCO) that they have been notified anonymously in the morning about a flu or virus outbreak at Pacifica. The anonymous tip described at least 12 residents in memory care. LPA Ascencio reached out to communicate with Admin Kortnie regarding a possible outbreak.
Continued on LIC 9099-C

Substantiated

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: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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 4

Control Number 29-AS-20220404114101

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: 04/12/2022

NARRATIVE

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LPA KaSandra Lopez spoke to Admin Kortnie on 4/4/22 and confirmed to LPA Lopez the facility does have an outbreak. Admin added that it started last week with residents in Memory Care and then on Thursday 3/31/22, a few more residents were sick with vomit and diarrhea. Admin continued; over the weekend we increase our dinning room tray service from seven (7) to eleven (11) in Assisted Living residents. Monday 4/4/22, Admin was told by staff that there are more resident that are sick and was going to follow up with LPA Ascencio. Admin continued, I am unsure how many residents and staff are sick, but we had about three (3) call out from staff last week. LPA Lopez asked Admin to complete incident repots and to report to VCPH since they had called Admin and left message. LPA Lopez reminded Admin to notify VCPH of any outbreak. As of 4/12/22, LPA Ascencio has yet to receive incident reports regarding staff and residents involved in the outbreak. LPA Ascencio reviewed the Illness Tracking form at 3:51 p.m. on 4/12/22, and it revealed the five (5) resident with symptoms started on 3/28/22 with vomiting and/or diarrhea; two (2) more resident on 3/29/22 with vomiting; three (3) staff with vomiting and diarrhea on 3/30/22; three (3) more residents on 3/31/22 with vomiting; one (1) staff and two (2) more residents on 4/1/22 with vomiting; five (5) residents presented with vomit and/or diarrhea on 4/2/22; nine (9) residents on 4/3/22 presented with vomit and diarrhea; six (6) residents on 4/4/22 presented with vomit; on 4/8/22 one (1) resident presented with vomit; and as of 4/10/22 two (2) resident were present with vomit.

Ongoing communications with VCPH on 4/12/22 stated that they have been out to the facility twice (2). They have complied with our request and recommendations. However, VCPH has had to make multiple request for information and samples, so communication has been difficult. As of Sunday 4/10/22's update, thirty-six (36) residents and four (4) employees present sick or with symptoms. VCPH added, the facility did not self-report. VCPH received an anonymous phone call stating there was a large number of memory care residents sick with symptoms. The outbreak had been going on for a week before VCPH got involved. VCPH did provide sample kits and instruction on how to collect samples. As of 4/12/22, the facility has not provided stool samples.

Interview with Admin Kortnie at 3:30 p.m. on 4/12/22, stated that some resident’s family members were informed of the symptoms, isolation and outbreak of the facility. Around 1/3 of the resident were notified but the others I’m not sure. We have had isolation gowns, gloves and mask to take care of those with symptoms. We placed a basket outside their room with all the Personal Protective Equipment (PPE) for staff to use.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20220404114101

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: 04/12/2022

NARRATIVE

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We stopped communal dinning and all activities at the building. We have been following the guidance and recommendation from VCPH since the day we notified them on 4/4/22.

Starting at 4:33 p.m., interviews with seven (7) residents out of the thirty-seven (37) that presented with symptoms stated that they isolated in their rooms, there was no communal dinning or activities and that their responsible party were informed of the outbreak situation. On 4/12/22, at 4:36 p.m., LPA reviewed the med-tech communications log from residents that reside in Memory Care and noted that one (1) resident out of eleven (11) residents that presented symptoms from the Illness log, were called and documented. On 4/12/22, at 5:32 p.m. , LPA reviewed the med-tech communication log from residents that reside in Assisted Living and noted that eleven (11) out of twenty-five (25) resident that presented symptoms from the Illness log, were called and documented. At 5:12 p.m., LPA received two (2) letters to families and residents, one dating 4/4/22 and 4/10/22, regarding the outbreak and the recommendation measure put in place by VCPH.

Based on interviews, document gathered, and observations, the allegation, facility failed to handle outbreak appropriately is deemed 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.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20220404114101

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: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/13/2022 Section Cited CCR 87211(a)(2)	1 2 3 4 5 6 7	87211 Reporting Requirements (a)(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.	1 2 3 4 5 6 7	Admin stated they will submit Incidents reports. Admin will conduct training regarding reporting requirements and documentation. Admin will submit a mitigation plan by 04/27/22 to LPA Ascencio via email.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: The facility did not comply with the section cited above as the facility did not report an outbreak to the appropriate agencies in a timely manner which posses and immediate health, safety and personnal rights risk to person in care.	8 9 10 11 12 13 14
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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 Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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