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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 04/12/2022
Date Signed: 04/18/2022 01:47:00 PM

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
02/03/2021 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210203122326
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: 59DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
11:09 AM
ALLEGATION(S):
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Facility has no Administrator
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver final findings for the above allegation. LPA met with Administrator Kortnie Spitznogle and explained the reason for the visit. The report was signed by Resident Service Director Kelly Newcomb as the Administrator had to leave the facility.

Based on interviews and record review, the facility administrator at the time of this complaint was Paul Markovich. From approximately 1/13/2021 through approximately 2/8/2021 the administrator was out of the facility due to COVID-19 infection. Two qualified staff were left in charge as acting administrators during that time: Sara Gutierrez and Marta Tapia under the guidance of Paul Markovich by phone. Based on the documentation and interviews, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and a copy of the report issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
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
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
02/03/2021 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20210203122326

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: 59DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
11:09 AM
ALLEGATION(S):
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Staff are not providing adequate food service
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Kortnie Spiznogle and explained the reason for the visit. The report was signed by Resident Service Director Kelly Newcomb as the Administrator had to leave the facility.

Beginning on approximately 07/16/2020, the facility experienced COVID-19 outbreaks throughout the remainder of the year and into January of 2021. During that time, under orders of Department of Public Health, the facility had to cancel group activities and communal dining. Residents who were interviewed confirmed that prior to the outbreaks the facility food service was good. However, the facility cooks all quit in November and December of 2020 and the food service was inadequate.

continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
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: 2 of 4
Control Number 29-AS-20210203122326
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 Camara interviewed residents and staff on 11/04/2021. During the COVID-19 outbreaks at the facility all residents were served meals in their room due to isolation protocols set forth by the Department of Public Health. During that time period the facility lost nearly all of their cooks. Other facility staff, including management, helped with cooking while the facility searched to hire new cooks. They offered menu items suggested by their corporate office, they were taught how to make the menu items and they offered alternative menu items. However, residents who were interviewed indicated there was a short period of time when all they received were sandwiches. In addition, residents indicated that some of the food they received was cold when it should have been hot. One caregiver indicated that was a possibility depending on where the resident's room was located as they may have been served last. Based on interviews with staff and residents, this allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D)


Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
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-20210203122326
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 B
04/12/2022
Section Cited
CCR
8755(a)
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8755(a) General Food Service Requirements. (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and
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Licensee previously submitted on 03/28/2022 evidence of management training regarding a plan for future instances where all residents must receive tray service due to an isolation order.
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healthful manner. This requirement was not met as evidenced by: Based on interviews, while tray service was being provided to all residents due to COVID-19, some residents were receiving cold food which should have been served hot, which posed a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
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)
Page: 4 of 4