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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 01/06/2023
Date Signed: 01/06/2023 05:07:16 PM


Document Has Been Signed on 01/06/2023 05:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:KORTNIE SPITZNOGLEFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 50DATE:
01/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Cynthia GarciaTIME COMPLETED:
03:35 PM
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
Licensing Program Analyst (LPA) Angel Ascencio arrived unannounced to conduct a Case Management – Other visit. The LPA met with Business Office Manger (BOM) Cynthia Garcia and explained the reason for the visit. Executive Director Kortnie Spitznogle was not able to attend. Entrance interview conducted.

This visit was regarding ongoing concerns related to the current Coronavirus (COVID-19) Outbreak. Community Care Licensing (CCL) received a faxed incident report from this facility on 12/29/2022, indicating that a resident had tested positive for COVID-19 on 12/26/2022. The Department obtained a letter dated 12/30/2022 that was addressed to the residents and families of this facility, indicating that the facility had ceased communal dining and group activities due to the rising cases of COVID-19. Although the letter indicated that this plan had been discussed with the local health department and CCLD, current guidance as detailed in Provider Information Notices (PINs) and the local health department does not support the above-mentioned plan.

PIN 21-49 ASC, which was released 11/17/2021, indicates that ‘Facilities may not prohibit residents from eating in the same room and/or at the same table, unless those residents are on isolation or quarantine precautions. Facilities may not prohibit residents from participating in group activities so long as there is appropriate hand hygiene, unless those residents are on isolation or quarantine precautions…. Residents who are not on isolation or quarantine precautions retain the right to participate in communal dining and group activities, regardless of their vaccination status. However, during an outbreak in the facility, the local public health department may require cessation of all communal dining and group activities until transmission has been contained.’ The investigation revealed that at this time, the local health department did not require this facility to cease communal dining and/or group activities. Per guidance from the Department, licensees must uphold the personal rights of residents by allowing residents and visitors to participate in communal dining and activities.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/06/2023
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
Lastly, the investigation revealed that whereas the Administrator initially informed Ventura County Health Department (VCPH) about the initial cases of COVID-19, but no communication since the initial discussion, and VCPH was unaware of the cases of COVID-19 until they were informed by CCL.
This is a repeat violation. A civil penalty of $250 is also assessed.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Civil penalties assessed. A copy of the report, along with appeal rights, were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/06/2023 05:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2023
Section Cited

1
2
3
4
5
6
7
87468.2(a)(6) Additional Personal Rights of Residents in Privately Operated Facilities. Residents …. shall have all of the following personal rights: To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agreed to do the following:
1. Review PIN 21-49 ASC and submit a statement of understanding, indicating how the facility will maintain voluntary compliance. Submit statement by 1/9/2023.
2. Submit an updated letter to residents and responsible parties, indicating the plan moving forward as it relates to the current outbreak. Submit the letter by 1/9/2023
8
9
10
11
12
13
14
Based on interview, the licensee did not comply with the section cited above, as the facility has not allowed residents whom are not on isolation or quarantine precautions to participate in communal dining or activities, which poses an immediate personal rights risk to residents in care.
8
9
10
11
12
13
14
Type A
01/09/2023
Section Cited

1
2
3
4
5
6
7
87211(a)(2) Reporting Requirements. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
1
2
3
4
5
6
7
The Administrator agreed to do the following:
1. Report the cases to VCPH by 1/9/2023
2. Conduct training regarding reporting requirements and documentation. Submit training documents to CCL no later than 1/13/2023
8
9
10
11
12
13
14
This requirement is not met as evidenced by:
Based on interview, the licensee did not comply with the section cited above as the facility did not report an outbreak to the appropriate agencies in a timely manner, which poses an immediate health, safety and personal rights risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3