565802425-8-12-2021-31-AS-KHEN-C5XQBG-20210816120131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 08/12/2021
Date Signed: 08/12/2021 11:38:49 AM

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
10/17/2019 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 31-AS-20191017141902

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: 44	DATE:	08/12/2021
		UNANNOUNCED	TIME BEGAN:	10:43 AM
MET WITH:	Sara Gutierrez		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff are overmedicating residents.
Medications are not properly stored and locked.
Staff handling residents in rough manner causing skin injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted an unannounced, subsequent complaint visit to deliver final investigation findings for the above complaint allegations. Entrance interview conducted.

It was alleged that staff were overmedicating residents, as resident #1 (R1) was overmedicated by staff and was transported to the emergency room on 10/13/19. During the course of the investigation, LPA conducted interviews with R1 on 11/22/19 at 1:08 pm, S4, S5 and S6 on 6/5/2020 starting at 12:03 pm. Interviews and information gathered revealed that R1 denied being overmedicated by staff and staff were not aware of R1 ever being over medicated. Furthermore, LPA also gathered and reviewed pertinent documentation on 11/22/19 starting at 10:45 am and on 11/22/19 starting at 10:45 am. Medication records did not reveal that staff were overmedicating R1, and hospital discharge records dated 11/22/19 did not reveal that R1 had any abnormal medication toxicity in R1’s body.

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: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

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 31-AS-20191017141902

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: 08/12/2021

NARRATIVE

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Based on all information gathered the above allegation, “Staff are overmedicating residents” is deemed unsubstantiated at this time.

It was further alleged that; staff did not properly store or lock medication (medications left on counters by S4). During the course of the investigation, LPA conducted interviews with S4, S5 and S6 on 6/5/2020 starting at 12:03 pm and S1 on 11/22/19 at 10:27 am. Interviews conducted revealed staff denied not properly storing resident medications or observing any medications left out on counters that should have been properly stored. Furthermore, LPA also toured the facility on 11/22/19 and 10/18/19 observing residents’ medications properly stored and locked. Based on all information gathered the above allegation, “Medications are not properly stored and locked” is deemed unsubstantiated at this time.

An additional concern alleged that staff handle residents in a rough manner causing skin injuries (scratching residents causing skin tears). During the investigation, LPA conducted interviews with S1, S2 and S3 on 11/22/19 starting at 10:27 am, S4, S5 and S6 on 6/5/2020 starting at 12:03 pm, R2 and R3 on 11/22/19. Interviews conducted revealed that staff were not aware of any residents being handled in a rough manner causing skin injuries. Furthermore, residents interviewed denied being mistreated nor scratched by staff. Based on all information gathered the above allegation, “Staff handling residents in rough manner causing skin injury (scratching residents causing skin tears)” is deemed unsubstantiated at this time.

Exit interview conducted. A copy of this report issued to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

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