565802425-4-26-2022-29-AS-KHEN-CDXUBY-20220429152708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 04/25/2022
Date Signed: 04/26/2022 10:38:54 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,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2020 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200519114053

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: 56	DATE:	04/25/2022
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Kortnie Spitznogle		TIME COMPLETED:	05:33 PM

ALLEGATION(S):

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Facility staff is not dispensing medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 10:01AM to conduct a subsequent complaint investigation, with the purpose of delivering findings for the allegation listed above. LPA met with facility Executive Director Kortnie Spitznogle. Entrance interview conducted.

During today's visit, LPA Ascencio toured the facility at 12:30PM. Previously, on 05/27/2020, due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA conducted the initial visit telephonically with Executive Director Ken Mahler at 12:15PM. LPA Dulek conducted a telephone interview with the administrator at 12:18PM, requested documents via email, and concuted a medication audit via FaceTime with the med tech at 3:43PM. LPA then reviewed the documents recieved, conducted telephone interviews with staff and residents. The following was then determined:

Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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 4

Control Number 29-AS-20200519114053

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: 04/25/2022

NARRATIVE

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During the subsequent complaint visit conducted on 05/27/2020, LPA Dulek conducted FaceTime video call to conduct a medication audit for Resident #1 (R1) and review of Resident #2 (R2)’s medication at 3:43PM. LPA observed that although Staff #1 (S1) stated that R1’s routine medication Atropine was discontinued as of Friday 5/22/2020, documentation on the MAR reflects the medication was administered at 5:00PM on 5/26/2020. S1 indicated this is an error on the electronic MAR, but there is handwritten documentation of the error. Handwritten documentation was unable to be provided to the LPA upon request. Additionally, R1’s Senna-Docusate was not initialed as administered on 5/13/2020 and 5/16/2020. Further review of the MAR pass notes indicates that on 5/14, 5/15, 5/18, 5/19, 5/20, and 5/21/2020 “waiting for med delivery.” Staff #1 (S1) indicated that the new pack of R1’s Senna Docusate was started on 5/20/2020 and LPA observed 21 pills remaining in the bubble pack. LPA Dulek requested a copy of the physician’s orders to discontinue R1’s daily Atropine and a copy of the medication destruction record for the Atropine. The LPA also requested a copy of the documentation indicating the electronic MAR error for R1’s Atropine on 5/26/2020. Administrator agreed to email all requested documentation by the end of business on 5/27/2020. Documentation was later discussed with the facility Executive Director, but no additional documentation was received. Therefore, based on record review and observation, the allegation that "Facility staff is not dispensing medication as prescribed" is deemed SUBSTANTIATED at this time.

This allegation was previously substantiated for R1 and R2 on 03/25/2022 via complaint control # 29-AS-20200519123141. Therefore, no citation will be issued today.

Exit interview conducted with Executive Director Kortnie Spitznogle. A copy of the report was provided via email.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
05/19/2020 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200519114053

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: 56	DATE:	04/25/2022
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Kortnie Spitznogle		TIME COMPLETED:	05:33 PM

ALLEGATION(S):

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Facility staff did not notice a change in the resident's condition
Facility staff do not allow resident to have guests

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20200519114053

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: 04/25/2022

NARRATIVE

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Regarding the allegation: "Facility staff did not notice a change in the resident's condition:"

Record review revealed that Resident #1 (R1) was admitted to hospice 02/27/2020 and moved into the facility on 02/29/2020. R1 had a private caregiver working with them the entirety of the resident's stay at the facility. Hospice physician changed R1's orders based on R1's changes in condition. Care notes indicated that R1 was changed to a puree diet on 05/22/2020 as well as a medication change on this date. Records indicate when new orders were made through hospice, the orders were provided and reviewed with the facility staff. No additional significant change in condition was noted during R1's time residing at the facility. Interview with R1 and R2, who was R1's spouse, indicated staff are able to assist R1 out of bed and into a wheelchair. R1's physician's report dated 02/06/2020 indicates R1 is non-ambulatory. Care notes indicated R1 preferred to remain in bed, however there was no documentation that this was a change in condition rather than a preference. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation, therefore the allegation that "facility staff did not notice a change in the resident's condition" is deemed UNSUBSTANTIATED at this time.

Regarding the allegation: "Facility staff do not allow resident to have guests:"

At the time of the complaint, due to Coronovirus-19 (COVID-19) and to implement mitigation measures, Ventura County Public Health had issued orders for limited visitation in congregate living facilities. Public Health orders did allow for visitation for end of life situations and R1 was on hospice the entirety of their stay at the facility. Visitation logs were provided and reviewed for 5/18/2020 - 05/26/2020. Care notes reviewed indicated R1's family members called on 05/22/2020 and requested a visit with R1. Visitation logs indicate R1 had visitors signed into the facility on 05/23/2020. Interviews revealed that R1 did have a private caregiver daily and this private caregiver did not allow R1 additional visitors, but the facility was following Ventura County Public Health orders and did not restrict R1's guests. Based on interview and record review, although the allegation may be valid, there is insufficient evidence to prove a violation occurred, therefore the allegation that "facility staff do not allow resident to have guests" is deemed UNSUBSTANTIATED at this time.

Exit interview conducted with Executive Director Kortnie Spitznogle. A copy of the report was provided via email.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC9099 (FAS) - (06/04)

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