565802425-4-26-2022-29-AS-KHEN-CEU225-20220527170009

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 04/25/2022
Date Signed: 04/26/2022 10:27:24 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
12/30/2020 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20201230085801

FACILITY NAME:	PACIFICA SENIOR LIVING OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	MARKOVICH, PAUL		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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Personnel were not trained for the job(s) assigned to them.
Facility did not maintain adequate staffing to meet resident(s) needs.
Resident(s) call lights are not being answered.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint inspection at the facility today with the purpose of delivering findings for the above allegations. The LPA arrived at 10:01AM and met with Executive Director Kortnie Spitznogle. The LPA informed Executive Director of the reason for today's inspection.

During today's visit, LPA Ascencio conducted a facilty tour beginning at 12:30PM. During the initial complaint visit on 01/06/2021, LPA Dulek conducted a telephone interview with the administrator at 4:05PM, a video call at 4:24PM, and LPA requested copies of pertinent documents. During a subsequent complaint inspection on 10/26/2021, LPA conducted resident interviews between 11:05AM and 12:50PM. During a previous visit on 10/21/2021, LPA Dulek conducted a facility tour with Business Office Manager Cynthia Garcia and Resident Care Director Marta Tapia at 12:09PM, conducted staff interviews between 12:33PM and 2:30PM and resident interviews between 2:48PM and 3:35PM and gathered copies of pertinent documents. The following was then
concluded: 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-20201230085801

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 "personnel were not trained for the job(s) assigned to them:"
Interviews with Management revealed that during the time period surrounding the complaint allegations, the facility was experiencing staffing shortages. The Administrator had called the LPA and let her know there were no dining room staff, the cook had also left the facility. During that time period, other facility staff, including management, helped with cooking while the facility searched to hire new cooks. Administrator stated to LPA that they were not trained to work in the kitchen and the management staff were filling in and had made sandwiches for the residents. Additionally, the management staff cooked the holiday meal for the residents. Another staff interview revealed they were "thrown into the kitchen to cook." Staff interviews revealed that while there is a plan for training staff prior to working in the facility, due to lack of available staff, staff are asked to cover shifts in other departments prior to receiving the appropriate cross-training. Based on interview, the allegation that "personnel were not trained for the job(s) assigned to them is deemed SUBSTANTIATED at this time.

Regarding the allegation "Facility did not maintain adequate staffing to meet resident(s) needs:"
LPA reviewed staffing records provided for December 2020. The following was found: only one caregiver working from 6:00AM-8:31AM on 12/30/2020. A second caregiver arrived at 8:31AM and a third caregiver arrived at 10:02AM. The facility's Mitigation Plan indicated staff were not to be shared between Memory Care and Assisted Living, but on 12/30/2020, there was only one caregiving staff working for all residents in the building. Additionally, on 12/20/2020 and 12/17/2020 during the NOC shift, there was only 1 caregiver working overnight. Interviews with staff revealed the facility was short staffed due to staff calling out for their scheduled shifts. Sometimes management would come in and cover the shifts, but not always. When caregivers call out, the medication technician can help out with caregiving tasks. At the time of the complaint, caregiver duties included assisting residents with ADLs, showering residents, and doing laundry for the residents, as well as light housekeeping duties. Staff interviews revealed that 2 or 3 caregivers for Assisted Living and one for Memory Care are scheduled during the am and pm shifts and one on each side for the NOC shift. According to staff, there were 3-4 residents that required a 2-person assist and at the time of the complaint there were 53 residents in the facility. One resident indicated "some days they don't have enough people" which results in long wait times for the residents who require assistance. Therefore, based on interview and record review, the allegation "facility did not maintain adequate staffing to meet resident(s) needs" is deemed SUBSTANTIATED at this time.

Report continued on LIC 9099-C

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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Control Number 29-AS-20201230085801

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 "resident(s) call lights are not being answered:"
LPA Dulek reviewed SMARTcare records for call lights during the time period of 12/31/2020 - 1/7/2021. The following was noted: over 100 times during the one-week period, response time was greater than 15 minutes. An additional 16 times the call was marked as "response required but not received...This alert was never responded to." Staff interview revealed that staff are required to respond to calls within 2-3 announcements, which allows for approximately 15-minute response. Staff stated that sometimes if all staff are busy assisting other residents, residents calling for assistance need to wait longer. Resident interviews revealed that often residents are waiting for half-hour to 45 minutes for assistance and that "it depends on the day how long the response time is. Some days they don't have enough people." 5 of 5 residents interviewed agreed that call response times vary and are often too long. Therefore, based on record review and interview, the allegation that "resident(s) call lights are not being answered" 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, appeal rights discussed, and a copy of this report and appeal rights were 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: 3 of 4

Control Number 29-AS-20201230085801

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/09/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to maintain adequate staffing and will send a copy of facility's staffing plan to include positions facility is recruiting for, plan to hire and train staff, and staff schedule to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the facility only had only one caregiver working on 3 different dates, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 05/09/2022 Section Cited CCR 87555(b)(18)	1 2 3 4 5 6 7	87555 General Food Service Requirements(b) The following food service requirements shall apply: (18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide proof of sufficient kitchen and dining room staff, along with their training records to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interview, during COVID, the facility did not have any kitchen staff nor cooks and the Administrator and other untrained staff were cooking the food for the facility, which poses a potential health risk to residents in care.	8 9 10 11 12 13 14

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

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

LIC9099 (FAS) - (06/04)

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