565802425-5-25-2022-29-AS-KHEN-CEY29D-20220531171144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 05/24/2022
Date Signed: 05/25/2022 08:37:03 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
05/12/2022 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20220512103100

FACILITY NAME:	PACIFICA SENIOR LIVING OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	KORTNIE SPITZNOGLE		FACILITY TYPE:	740
ADDRESS:	2211 E GONZALES RD		TELEPHONE:	(805) 983-6808
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	100	CENSUS: 54	DATE:	05/24/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Cinthia Garcia		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Staff are not wearing masks

INVESTIGATION FINDINGS:

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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 05/12/2022 alleging that facility staff are not wearing masks. On 05/17/2022, LPA Ascencio toured the facility at 09:55 a.m. and observed all staff and visitors wearing their mask propely around the community. LPA also witnessed the front desk have a box of surgical mask readily available for staff and visitors if needed. On 05/24/2022 starting at approximately 9:30 a.m., LPA Ascencio toured the comnunity and interviewed staff and residents. Interview with four (4) residents starting at 9:33 a.m. revealed that staff are always seen wearing their mask. Visitors typically wear their mask also but sometimes they just run in real quick and leave. Mask are always available at the front desk.

Continued on LIC 9099-C

Unsubstantiated

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: 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)

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Control Number 29-AS-20220512103100

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

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Six (6) staff interviews beginning at 09:43 a.m. revealed that it is mandated for staff and visitors to wear a mask. Interviews with staff also confirmed that staff has had training on mask requirements and personal protective equipment (PPE) and that they have seen posted throughout the facility about having to wear a mask. Additional information from the staff interviews revealed that the facility provides staff with mask if they are in need of one and the mask can be found at the front desk, in the medication room or in any of the directors office. Based on information gathered, the allegation of staff are not wearing masks is deemed unsubstantiated at this time.

Exit interview conducted and copy of the report 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: 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)

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