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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 09/23/2022
Date Signed: 09/23/2022 05:27:28 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
09/10/2020 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200910115337
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: 52DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
05:33 PM
ALLEGATION(S):
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Facility has scabies outbreak
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 11:12 AM to conduct a subsequent complaint investigation for the allegation listed above. LPA met with facility Executive Director Kortnie Spitznogle. Entrance interview conducted.

During today's visit, LPA Dulek interviewed Administrator at 11:15AM, staff at 11:54AM, and LPA reviewed and obtained copies of pertinent documents. Previously during a subsequent complaint inspection conducted on 04/25/2022, LPA Ascencio toured the facility at 12:30PM, and LPA Dulek requested pertinent documents, however the documents were unavailable at the time of the visit. During an initial virtual complaint visit, which took place on 09/21/2020, LPA Dulek conducted a telephone interview with the RCD and requested pertinent documents, which were not received. During unrelated complaint visits conducted in person at the facility, LPA Dulek conducted staff and resident interviews related to this complaint. The following was then determined:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 6
Control Number 29-AS-20200910115337
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: 09/23/2022
NARRATIVE
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It was alleged that the facility has a scabies outbreak. Interview revealed that there were 4 residents in the facility that had been diagnosed with scabies during the time period of the complaint allegation. Review of records for Resident #1 (R1), whom the complaint allegation references, did have a diagnosis of scabies as of 07/01/2020. R1 was prescribed medication for the diagnosed case of scabies. Additional record review revealed this scabies case was not reported to CCL or to Ventura County Public Health, per regulation. Based on record review and interview, the allegation that "facility has a scabies outbreak" is deemed SUBSTANTIATED at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D.)

Executive Director was informed that civil penalties may be assessed at a later date based on Health and Safety Code 1569.49(f). Exit interview conducted, appeal rights discussed, and a copy of this report was issued via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
09/10/2020 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20200910115337

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: DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
05:33 PM
ALLEGATION(S):
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Resident suffered multiple falls resulting in injuries.
Staff did not bathe resident.
Staff illegally evicted resident.
Staff did not administer medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility at 11:12 AM to conduct a subsequent complaint investigation for the allegations listed above. LPA met with facility Executive Director Kortnie Spitznogle. Entrance interview conducted.

During today's visit, LPA interviewed Administrator at 11:15AM, staff at 11:54AM, conducted a medication audit at 03:54PM, and LPA reviewed and obtained copies of pertinent documents. Previously during a subsequent complaint inspection conducted on 04/25/2022, LPA Ascencio toured the facility at 12:30PM, and LPA Dulek requested pertinent documents, however the documents were unavailable at the time of the visit. During an initial virtual complaint visit, which took place on 09/21/2020, LPA Dulek conducted a telephone interview with the RCD and requested pertinent documents, which were not received. During unrelated complaint visits conducted in person at the facility, LPA Dulek conducted staff and resident interviews related to this complaint. The following was then determined:
Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20200910115337
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: 09/23/2022
NARRATIVE
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Regarding the allegation "Resident suffered multiple falls resulting in injuries:"
Record review revealed that Resident #1 (R1) had fallen six (6) times during the time period of 06/17/2020 - 08/21/2020. Review of R1's physician's report indicates R1 is non-ambulatory with a diagnosis of dementia. R1 was able to ambulate using a wheelchair. R1 was noted to be able to follow instructions, able to transfer themself and able to communicate their needs. Record review did not reveal that R1 was a fall risk. Although it is possible that R1 had a change of condition, as the care notes dated 07/06/2020 after R1 had returned from the hospital, indicated R1 was "having a hard time walking." No new care assessment or physician's report was completed, so it is unclear whether R1 did have a change of condition or not. Resident Assessment review revealed R1 was independent in most ADLs, including transfers and did not require an escort to ambulate. While record review did indicate R1 had fallen multiple times, there was no documented evidence indicating the falls were sustained as a result of lack of care and supervision. As thus, although the allegation may be valid, based on record review, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "resident suffered multiple falls resulting in injuries" is deemed UNSUBSTANTIATED at this time.

Regarding the allegation "Staff did not bathe resident:"
During the complaint investigation, LPA reviewed records for R1 and interviewed staff and residents. R1 no longer resided at the facility at the time of the interviews, however resident interviews revealed that showers are currently offered and assisted with on time and on schedule. Record review for R1 indicated R1's needs and service assessment did not include shower assistance, nor did R1's resident pre-placement appraisal indicate shower assistance was needed. However, physician's report did indicate R1 required bathing assistance. Care notes reviewed indicate R1 was showered on 08/13/2020 and 08/15/2020. R1 was hospitalized then R1 moved out of the facility as of 08/21/2020. There was no record of how often R1 was to be assisted with bathing. As thus, although the allegation may be valid, based on record review and interview, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "staff did not bathe resident" is deemed UNSUBSTANTIATED at this time.

Regarding the allegation "staff illegally evicted resident:"
It was alleged that when family arrived at the facility, R1's belongings were packed up and R1 did not return to the facility. Emails between Pacifica Senior Living management members and R1's family were reviewed during the complaint process. Emails reviewed indicate management staff had been in communications
Report Continued on LIC 9099-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20200910115337
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: 09/23/2022
NARRATIVE
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with R1's family and that alternate placement suggestions had been made for R1's changing care needs 2 days prior to R1 moving out of the facility. The day prior to R1 moving out of the facility, management had exchanged emails indicating "we have not issued a 30 day notice at this time." However, the management team had discussed R1's care needs. Emails indicate R1's family had asked Pacifica to communicate with alternate placement, with the hopes R1 could move to another facility. Care notes indicate R1 moved out of the facility, however it is unclear whether the facility moved the resident out or if the facility evicted R1. Interview with staff revealed that the resident was not evicted to their knowledge, however additional communications with R1's family may have occurred with the Executive Director employed with the facility at that time. The Executive Director left employment effective 08/27/2020 and therefore was unavailable to interview regarding this complaint. Although the allegation may be valid, based on record review and interview, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "staff did not bathe resident" is deemed UNSUBSTANTIATED at this time.

Regarding the allegation "Staff did not administer medications as prescribed:"
It was alleged that R1's 6:00 medications were not administered on time, as they were administered at 06:20. R1 was no longer residing at the facility and had taken their medications with them and therefore unable to be audited during the complaint process. During the visit on 09/23/2022, LPA conducted a medication audit for 3 residents. All 3 of 3 residents' medications reviewed were administered as prescribed. Care notes for R1 did not indicate any discrepancies in medications administered. Communication between the facility and R1's physician was reviewed and did not indicate any medication discrepancies. On 08/14/2020 there was a change in orders indicating medication Quetiapine 25mg was changed from TID to BID (8am and 12noon) and Quetiapine 50mg QPM. However no documentation was able to be reviewed regarding times the medications were administered, nor was there specific dates indicated in the allegation to review what the doctor's orders were at that time. Interviews revealed medications are given on time as prescribed. Although the allegation may be valid, based on record review and interview, at this time there is insufficient evidence to prove a violation occurred; therefore the allegation that "staff did not administer medications as prescribed" is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. A copy of the report was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20200910115337
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: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited
CCR
87211(a)(2)
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87211 Reporting Requirements (a)(2) Occurrences, such as epidemic outbreaks, ...or major accidents which threaten the welfare, safety or health of residents...shall be reported within 24 hours either by telephone or facsimile to the licensing agency
This requirement is not met as evidenced by:
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Administrator has agreed to submit Incident Reports to CCL in the timeline reflected in section 87211. Administrator indicated a training was conducted in May 2022 regarding reporting requirements and proof was sent to CCL at that time. POC cleared
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Based on interview and record review, the licensee did not comply with the section cited above, as R1 was diagnosed with scabies, yet CCL was not notified, which poses a potential personal rights risk to residents in care.
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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: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6