<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:56:54 AM

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
07/13/2020 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20200713160044
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: 54DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cinthia GarciaTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not provide new facility with resident's personal belongings.
Facility staff did not clean resident's room.
Facility did not provide resident with proper refund.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to deliver final findings. LPA met with Business Office Manager (BOM) Cinthia Garcia at 9:45 a.m. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 07/13/2020 alleging that facility staff did not clean resident’s room, facility staff did not provide new facility with resident belonging, and facility staff did not provide proper refund.

On 07/22/2020 starting at approximately 11:20 a.m., LPA Kelly Dulek conducted an interview with former ED. During the interview, it was revealed that the facility cleans all the common areas daily and the housekeepers have a schedule for room cleaning with each room being serviced once (1) a week. The housekeepers go into the resident’s rooms and pick up trash, vacuums and clean the restrooms.
Continued on LIC 9099 - C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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 9
Control Number 29-AS-20200713160044
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: 05/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
If resident’s refuse the room cleaning, our staff will try to take out the trash. Further interview also revealed that the bus driver has been relocated to clean and disinfect since there are no outings. Later that same day, LPA Dulek also conducted staff interviews which revealed that housekeeping job entails cleaning hardwood floor, bathrooms, and dusting if possible. If a resident does not want to be disturbed, they will try to come back or come another day. If residents refuse, they would tell their manager and it would be documented. Further interview also revealed that Resident #1 (R1) always like their room being cleaned and they do not recall the room being messy or dirty while R1 lived at the facility. On 10/21/2021 and on 10/26/2021 LPA Ascencio conducted resident interviews. Interviews with residents revealed that the rooms are kept clean by housekeeping, who come to their room at least once (1) a week. The housekeepers clean, mop and vacuum the rooms. While conducting resident interviews, LPA Ascencio observed all resident rooms and restrooms clean, odor free and free from any clutter. LPA also reviewed the housekeeping schedule and observed resident room number being scheduled for service on a daily basis. Based on evidence gathered, this allegation is deemed unsubstantiated.

It is also being alleged that facility staff did not provide new facility with resident belonging. On 07/22/2020, LPA Dulek conducted an interview with former ED at approximately 11:20 a.m. During the interview it was revealed that former ED did not know about Resident #1 (R1) moving out until the day they moved out. ED added, I believe R1 was picked up by their Hospice company on Thursday June 10th and family came the next day to pick up R1’s items. Interview with R1’s representative on 07/13/2020, 07/23/2020, 08/25/2020 and 12/04/2020 revealed that R1 moved out of the facility on 06/08/2020 to be closer to family. R1’s representative attempted to communicate with Resident Care Director (RCD) the day before, 06/07/2020 but was not available at the time. R1’s representative called Pacifica Senior Living Oxnard the following day and told the facility R1was moving out the same day. R1’s representative continued, the new and old hospice companies arranged the transportation. The new company transported her in a wheelchair. The facility also had the medication ready but did not release it to the hospice company. R1 left with what they had on. LPA Dulek asked R1’s representative if they had instructed the facility to gather and pack up R1’s belonging. R1’s representative stated no, I assumed the facility would do so. LPA Dulek asked R1’s representative if they instructed the hospice company to gather and pack up R1’s belongings. R1’s representative stated no.

LIC 9099-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 29-AS-20200713160044
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: 05/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
R1’s representative went to the facility the following day, 06/08/2020, and gathered all of R1’s belongings. Although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is unsubstantiated.

Lastly, it is also being alleged that facility staff did not provide proper refund. Interview with R1’s representative on 07/13/2020 starting at approximately 10:05 a.m. revealed that on 06/07/2020 was the date R1 moved out from Pacifica Senior Living. The following day, 06/08/2020, R1’s representative removed all personal belonging from the room R1 was living in. On 03/18/2022 at approximately 2:30 p.m., LPA interviewed Business Office Manager (BOM). During the interview, it was revealed that there was an email between BOM, Former ED and Senior Regional Manager on 07/09/2020, which stated that the balance of R1 was approved to be "zero" our for teh month of May and June. LPA also received the balanced ledger for R1’s stay at the facility dating from 06/28/2018 through 07/09/2020. The ledger states room charge and care fee charges were stopped 06/06/2020. There was also a zero-balance statement for 07/2020. Further interview revealed that R1's representative gave a 30-day notice on 06/08/2020 and the Resident Agreements Form that was signed on 06/07/2018 states " You will continue to be responsible for your full Monthly Fee until the thirty (30) day period has expired. Based on evidence gathered, this allegation is deemed unsubstantiated.

Exit interview conducted. Copy of report provided to BOM and Admin via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 9
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
07/13/2020 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20200713160044

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: 54DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cinthia GarciaTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed pressure injuries while in care
Facility staff did not safeguard resident’s personal belongings
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility to deliver final findings. LPA met with Business Office Manager (BOM) at 9:30 a.m. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 07/13/2020 alleging that facility staff did not safeguard resident’s personal belongings and resident developed pressure injuries while in care.
On 07/13/2020 and 12/04/2020, LPA Kelly Dulek and LPA Lyndia Sager conducted an interview with Resident #1 (R1) representative. During the interview, it was revealed that R1 was admitted to the facility April 2018. On or around February 2020, R1 developed pressure sores on the backs of their heels but was unsure of when it started. In the second week of March 2020, R1 saw the Podiatrists and noted to have opened sores.

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: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 29-AS-20200713160044
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: 05/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
R1’s representative also added that R1 was initiated on Hospice services at the end of April 2020. R1 was taken out of the facility and relocated closer to family on 06/08/2020. R1 passed away August 2020. Interview with Former Administrator on 06/15/2020 starting at approximately 4:13 p.m. revealed that Administrator did not have any knowledge of any injury R1 had sustained. During a facility visit on 03/18/2022, LPA Ascencio received R1’s Needs and Services, Physician Communication Forms, Physicians Report LIC 602, Resident Assessment, Physician’s Orders and Residence and Care Agreement form. Review of R1’s Resident Assessment dated 01/08/2020 and signed by R1’s responsible party and Authorized Community Representative on 01/12/2020, revealed that R1’s Care Level for Bathing required one (1) Person Total Assistance two (2) times per week, Dressing required 1 Person Total Assistance, Toileting required stand-by assistance, Ambulation required 1 Person Total Assist or Wheelchair escort to and from, and Transfers required stand-by assistance. Review of R1’s Physician Report LIC 602 dated 04/27/2020 revealed that R1 had a diagnosis of Alzheimer’s Dementia, and their physician did not know the capacity for self-care due to knot being able to see R1 since December 20219. LPA Ascencio also reviewed R1’s Needs and Service Plan dated 05/06/2020 revealed that Bathing required total assist, Dressing required total assist, Toileting required stand-by assist, Ambulation required total assist, Transfers required standby assist, Hospice was initiated 4/29/2020, and Skin Integrity was added on 01/09/2020 and had care staff report any changes in condition to physician. LPA reviewed Narrative Charting Notes for R1 on 03/18/2022 and revealed that on 04/23/2020 R1’s representative was notified of putting R1 on hospice services. On 12-8-2020, LPA Sager interviewed Hospice Social Worker (SW) and it was revealed that R1 had skin tear and sores on both leg and staff would not give any information regarding R1 injuries. SW went back to the community and staff were not cooperating in telling us how R1 received the sores and skin tears. On 11/10/2021 and 05/04/2022, LPA Ascencio received Hospice care notes and pictures. Review of Hospice notes revealed that on 05/29/2020 the Hospice Agency received a call regarding a concern in skin tear and sore on R1’s body. SW stated that the facility staff do not know how it happened and would not give out any information to the SW. On 06/03/2020, the wound specialist arrived and since facility staff was uncooperative and unwilling to provide details regarding injuries, an Adult Protective Service report was filled and will be forwarded to Community Care Licensing (CCL).

Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 29-AS-20200713160044
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: 05/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Further review of the Hospice Notes revealed that on 05/02/2020, R1’a wounds included bilateral heel decubitus at a stage II (2)/ III (3), on 05/04/2020 staff not getting R1 up into wheelchair due to leaning over, staff are afraid R1 will fall, on 05/06/2020 bilateral heel decubitus progressed to Stage III with both heels appearing the same with small yellowing drainage on dressing with dressing sticking to heel, on 05/12/2020 right heel decubitus appears reddened with more purulent drainage and outer aspect of foot has a new pressure area stage 2 while the left heel decubitus has small drainage on dressing with new reddened area on inner aspect of big toe. Hospice nurse discussed with staff the importance or turning R1 every 2-3 hours to keep pressure decubitus from happening and end explained new pressure areas. Continued Hospice notes revealed that on 05/19/2020 bilateral heel ulcers are unstageable, on 05/22/2020 noted additional opened wounds on outer site aspect of right foot and instructed staff to continue with repositioning R1 every 2 hours and to ensure heels protectors are on to alleviate pressures on heels, on 05/23/2020 another pressure reddened area on outer aspect mid foot on left heel and right heel has another pressure area, scabbed outer area, on 05/26/2020 bilateral heel decubitus and pressure areas on both feet and wearing foam boots while in bed, on 05/30/2020 left heel outer aspect of foot, midway has pressure area 1 centimeter (cm) x 1 cm with open skin while right foot has pressure area outer aspect midway reddened all around but skin intact, on 06/02/2020 right outer buttocks has large reddened area, 5 cm x 7 cm skin intact still, on 06/04/2020 reminded staff to continue with repositioning R1 every 2 hours, to keep heel protectors on at all times and to continue elevating extremities, and on 06/06/2020 it was noted that a few days back, a med-tech called and reported redness around hips and buttocks area. No additional entries were made after this point as R1 was moved away from facility and discharged from Hospice services. Interview with Hospice Nurse on 05/23/2022 stating at approximately 2:55 p.m. revealed that R1 needed a higher level of care than what the facility was providing. I suggest to the R1’s representative to have R1 move to a Skilled Nursing Facility (SNF) but they did not want to. The facility R1 lived at was not a SNF. I believe R1 needed more. Yes, I educated the staff in repositioning, but I know it was tough. It’s tough to do that in a SNF, I believe it would be more difficult in a setting R1 was at. The staff tried but it wasn’t enough. Based on evidence gathered, the allegation resident developed pressure injuries while in care is substantiated at this time.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 9
Control Number 29-AS-20200713160044
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: 05/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation that facility staff did not safeguard resident’s personal belongings. Interview with R1’s representative on 07/13/2020, 10/20/2020, and 12/04/2020 revealed that the facility lost a hearing aid worth about two-thousand seven hundred dollars ($2,700) that the Senior Audiologist from UCLA Health quoted for. We sent the bill over to Pacifica. Interview on 07/22/2020 with Former Administrator at approximately 11:20 a.m. revealed that Administrator did not know about the missing hearing aid until about 1 week ago. Admin stated they have been looking for it but haven’t been successful. An entry from Hospice Notes dated 05/23/2020 revealed that the hospice nurse was unable to find the residents hearing aids when previously R1 has been wearing them. LPA reviewed R1’s LIC 602 Physician Report and stated R1 has an auditory impairment and needs assistance with putting them on. Interview with Business Office Manger on 05/23/2022 starting at approximately 5:15 p.m. revealed that when a resident loses an item, family is encouraged to submit a copy of the receipt with the cost of the item. BOM will submit that receipt to the Cooperate office who will issue refund. The families are encouraged to sign and fill out the Personal Property form, but some don’t. R1 did have hearing aids but we aren’t sure what happened to them. LPA Ascencio reviewed R1’s Resident Agreement form and stated on page seventeen (17), “ We shall not be responsible for the loss of any personal property belonging to you due to the theft, fire, or any cause, unless the loss or damage was caused by our own negligence or that of our employees. We strongly recommend that you obtain, at your own expense, insurance for the replacement value of your personal property, at adequate coverage and liability limits.” LPA Ascencio was provided by R1’s representative a letter sent to a Senior Managing Director in San Diego, Ca regarding the missing hearing aid and the cost of replacement. On an interview with former ED on 07/22/2020 starting at around 11:20 a.m. revealed that ED did have knowledge of the missing hearing aid after the Corporate office informed the ED of the letter and missing hearing aid. Based on record review and interviews, the allegation, that facility staff did not safeguard resident’s personal belongings is deemed substantiated at this time.

2 citation were issued during today's visit. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 9099-D).

2 civil penalty of $250 each, for a total of $500.00, is also assessed today for the facility repeating the same violation within a 12 month period. The Business Office Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).



Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 29-AS-20200713160044
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: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2022
Section Cited
HSC
1569.312(a)
1
2
3
4
5
6
7
1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Admin stated they will conduct training and provide copies to LPA via email.
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not comply with the section cited above as the licensee did not provide adequate care and supervision or seek higher level of care to R1 which attributed to R1 sustaining pressure injuries which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 29-AS-20200713160044
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: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2022
Section Cited
CCR
87217(b)
1
2
3
4
5
6
7
87217(b) Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff....
1
2
3
4
5
6
7
Admin stated they will be sending the reciept of the missing hearing aid to the cooprorate office to initiate a refund.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on interviews with witnesses, R1 was missing personal care items that was need as part of their care which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 9