565802425-7-13-2022-29-AS-KHEN-CHMQFU-20220825120827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 07/13/2022
Date Signed: 07/13/2022 03:55:03 PM

Substantiated

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
07/11/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20220711082056

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:	07/13/2022
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Kortnie Spitznogle, Administrator		TIME COMPLETED:	04:01 PM

ALLEGATION(S):

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Facility did not meet reporting requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an initial 10-day complaint visit at the facility today. At 10:20 a.m., the LPA was greeted and screened by staff. At 11:08 a.m., the LPA met with the Administrator, Kortnie Spitznogle and explained the reason for the visit.

Between 11:50 a.m. and 12:15 p.m., LPA Peraldi and the Business Office Manager, Cynthia Garcia conducted a physical plant tour. Between 10:27 a.m. and 12:10 p.m., LPA Peraldi interviewed six (6) out of fifty-four (54) residents and three (3) staff. At 11:10 a.m., LPA Peraldi conducted an interview with the Administrator. At 12:28 p.m., LPA Peraldi reviewed records and obtained copies of pertinent documents.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

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-20220711082056

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: 07/13/2022

NARRATIVE

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Regarding the allegation: Facility did not meet reporting requirements
On 07/11/2022, it was alleged that the facility did not report Resident #1’s (R1’s) death to Resident #1’s responsible party. On 06/30/2022, R1 passed away and the facility contacted R1’s Hospice Agency. On 07/01/2022, the facility sent R1’s death report (LIC 624A) to Community Care Licensing (CCL). On 07/11/2022, the Administrator and Business Office Manager contacted R1’s responsible party via email to coordinate the removal of the R1’s personal property. However, no phone call or a written report was submitted to the person responsible for the R1 within seven days of R1’s death. Interviews with staff and the Administrator revealed that R1’s Hospice agency contacted person responsible for R1 about R1 death. Interview with the Administrator revealed that the Administrator assumed that staff at the facility had already contacted person responsible for R1. During the time of R1’s death, the Administrator was on personal time off and was not physically at the facility. Furthermore, R1’s death report (LIC 624A) did not include or specify the person notified about R1’s death. The Administrator explained the miscommunication that occurred and explained that going forward the Administrator will ensure that the facility is in compliance with all required reporting requirements. Based on the information gathered, the above allegation is deemed Substantiated at this time.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and report reviewed with the Administrator. A copy of report and appeal rights will be provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220711082056

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: 07/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/22/2022 Section Cited CCR 87211(a)(1)(A)	1 2 3 4 5 6 7	87211(a)(1)(A) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: (A)Death of any resident from any cause regardless of where the death occurred… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: - Agreed to submit a Statement of Understanding, detailing how the facility will maintain compliance of Regulation 87211 and submit to CCL by 07/22/2022.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above as the facility failed to notify the person responsible for R1 of R1’s death which poses a potential health & 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 Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022

LIC9099 (FAS) - (06/04)

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