565802425-4-26-2022-29-AS-KHEN-CFD4WC-20220613192742

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 04/25/2022
Date Signed: 04/26/2022 10:37:39 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
08/27/2020 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200827142152

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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Staff failed to observe changes in resident's health
Facility has ant infestation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation with the purpose of delivering findings for the allegations listed above. LPA met with Executive Director Kortnie Spitznogle and discussed the reason for the visit. Entrance interview conducted.

During today's visit, LPA Ascencio toured the facility at 12:30PM. Previously, on 09/02/2020, LPA conducted an initial complaint investigation telephonically, which consisted of a telephone interview with the Resident Care Director, and a video call to conduct a virtual facility tour at 5:27 PM and a review of the pendant/resident call system at 5:36 PM. The LPA requested pertinent documents at that time. LPA then reviewed the documents and interviewed both residents and staff. 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 5

Control Number 29-AS-20200827142152

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 "staff failed to observe changes in resident's health:"
Assisted Living Resident Assessment dated 06/09/2020 indicates R1 requires 1-person assist with bathing, 1-person assist with dressing, grooming reminders, stand-by assistance with toileting, 1-person escort to and from activities, and 1-person assist with transfers, as well as medication assistance. Needs and service plan for R1 dated 09/03/2020 indicates total assist with dressing and grooming, 2-person assist with bathing, toileting, ambulation and transfers, as well as R1 is a fall risk and requires total assist with medications. Although the new needs and service plan does indicate a change in condition, the plan is not signed by the resident nor the resident’s responsible party so there is no indication this change of condition was communicated to R1’s responsible party nor R1's physician. On 08/19/2020, charting notes indicate R1’s tremors seem to be worsening and MD notified. Faxed note indicates “family notified,” however the note indicating “family notified” does not indicate who was told or when. Physician communication reviewed contained faxed notes to R1's physician, but none prior to 11/12/2020, during the time period of the complaint. Interview with resident’s responsible party revealed that the responsible party was not contacted nor made aware by the facility that R1 had a change in condition. Interview with Administrator on 12/17/2020, revealed that at the time of the complaint the facility was short-staffed and that communication with families and other pertinent parties was delayed at that time due to the staffing issues. Therefore, based on interview and record review, the allegation that "staff failed to observe changes in resident's health" is deemed SUBSTANTIATED at this time.

Regarding the allegation "Facility has ant infestation:"
During the virtual initial complaint inspection, LPA interviewed Resident Care Director (RCD) throughout the inspection. RCD indicated "yes, I have seen ants in the facility." RCD is aware of ants in the Directors' Offices, as well as in resident rooms. She has heard from at least 3-4 residents recently who complained of ants. RCD called a pest control company, who came last week to spray the exterior, but RCD indicated everything inside was not treated. RCD provided invoice from the pest control company which does reflect "exterior general pest control" was completed on 08/28/2020. Interview with residents revealed that 5 of 7 residents interviewed have seen ants and indicated there is an ant problem in the facility. Therefore, based on interview, the allegation "facility has ant infestation" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is 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)

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Control Number 29-AS-20200827142152

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 B 05/09/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes...ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to provide training to all staff on observing residents and will provide proof of training, including date, topics covered, names of attendees to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not notify R1's responsible party nor physician of a change in condition, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 05/09/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services....for the safety and well-being of residents, This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator will create a plan for ongoing pest control for the building and will provide the plan to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the Licensee did not assure that the facility remins free of ants, as 5 of 7 residents interviewed indicated the facility has an "ant problem" and Resident Care Director corroborated the facility has ants, 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)

Page: 3 of 5

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
08/27/2020 and conducted by Evaluator Kelly Dulek

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20200827142152

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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Staff not treating resident with dignity
Staff not assisting resident with ADLs

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: 4 of 5

Control Number 29-AS-20200827142152

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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caregivers," "they (caregivers) are nice not rude or disrespectful," and "are all very nice and kind." Staff interview revealed there are some residents who are a "bit feisty" but staff still treat them with dignity and respect. No staff interviewed have ever heard another staff say anything disrespectful to any resident. Based on interviews, although the allegation may be valid, at this time there is insufficient evidence to support the allegation. Therefore, the allegation that "staff not treating resident with dignity" is deemed UNSUBSTANTIATED at this time.

Regarding the allegation "Staff not assisting resident with ADLs:"
Record review revealed that R1 had a change of condition, which was reflected in a 09/03/2020 care plan. R1 then became a 2-person assist with most ADLs. Care notes indicated staff assisting R1 regularly. Staff interviews revealed staff assist with incontinence needs every 2 hours, or as needed. Residents who are on a 2-person assist, they call on the walkie-talkies for an additional care staff when needed. LPA observed staff attending to residents during facility visits. Resident interviews revealed that care staff do assist with ADLs regularly and residents stated they feel their needs are being met. Although the allegation may be valid, at this time, based on interview, there is insufficient evidence to support the allegation. Therefore the allegation "staff not assisting resident with ADLs is deemed UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted with Executive Director. 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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