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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 01/23/2023
Date Signed: 01/23/2023 03:32:01 PM


Document Has Been Signed on 01/23/2023 03:32 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: 51DATE:
01/23/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPAs) Ashley Smith and Angel Ascencio conducted an unannounced Case Management - Other visit to the above facility. The purpose of today's visit to ensure an excluded individual is not employed at the facility. The LPAs met with Executive Director Kortnie Spitznogle and explained the reason for the visit.

During today's visit, the LPAs inquired as to whether Staff #1 (S1) is currently employed at the facility. The Business Office Manager confirmed that S1 had submitted an application but was not actively working at this facility nor was S1 ghired. The Woodland Hills North Regional Office reviewed the legal case and the individual’s history and the Stipulation/Decision and Order excluded the individual for life. The individual is not eligible to be licensed, reside or work in a facility. The Decision and Order was served to the licensee and S1 via certified mail on 01/06/2023 and was effective as of 01/17/2023. The ED confirmed that they had received documentation regarding S1, which confirmed that S1 could not be employed at this facility.

In addition, LPA obtained copies of the staff roster to verify that S1 is not employed at the facility.

Exit interview conducted. A copy of report issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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