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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 03:33:22 PM


Document Has Been Signed on 01/23/2023 03:33 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ashley Smith and Angel Ascencio conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20230119090203.

At 12:20 p.m., the LPAs observed a fountain the courtyard in the memory care unit. The fountain had approximately two (2) inches of standing water at the bottom of the fountain.

At 12:22 p.m., the LPAs attempted to leave the enclosed courtyard in the memory care unit and discovered that the LPAs were unable to egress back into the facility. The LPAs had to wait for staff to open the door until they were able to get inside the main facility. This is a personal rights violation.

At 12:47 p.m., the LPAs observed the 3rd floor theater room, and identified that a screen was missing from a window. The window screen was on the floor. As a result, the window leads to an enclosed balcony area.

At 12:49 p.m., the LPAs observed the staff break room. There was an accessible knife observed in a drawer.

At 12:52 p.m., the LPAs observed accessible gardening supplies (soil) and tools in the courtyard.

At 12:53 p.m., the LPAs observed a fountain the main courtyard. The fountain had approximately four (4) inches of standing water at the bottom of the fountain. This is a zero-tolerance violation, which results in a civil penalty in the amount of $500.

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. Appeal Rights Discussed. A Copy of the 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)
Page: 1 of 3


Document Has Been Signed on 01/23/2023 03:33 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: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2023
Section Cited

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87307(e) Personal Accommodations and Services. Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water...through fencing, covering or other means.
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The ED agreed to do the following:
1. Water features will be drained of water by end of the day, 1/23/2023.
2. Rocks would be placed in the water features to ensure water depth does not pose a hazard to residents in care. Send photos once completed.
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This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above as the facility had water fountains in the courtyard and in front of the building filled with standing water, which poses an immediate health and safety risk to persons in care.
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This is a zero tolerance violation; civil penalty in the amount of $500 assessed.
Type A
01/23/2023
Section Cited

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87309(a) Storage Space. Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
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The ED agreed to secure the items by the end of the day, 1/23/2023.
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Based on observation, the licensee did not comply with the section cited above, as a knife was accessible in the staff room and accessible gardening supplies and tools in the courtyard, which poses an immediate health and safety 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/23/2023 03:33 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: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2023
Section Cited

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87468.1(a)(6) Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
This requirement is not met as evidenced by:
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The ED agreed to do the following:
1. Submit a statement, detailing how the community will regain compliance with Regulation 87468.1(a)(6). Submit statement to CCL no later than 1/24/2023, end of day.
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Based on interviews, the licensee did not comply with the section cited above, as the exterior doors to the courtyard in the memory care unit are locked from the inside, which poses an immediate personal rights risk to residents in care.
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Type A
01/24/2023
Section Cited

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87303(c) Maintenance and Operation. All window screens shall be clean and maintained in good repair.
This requirement is not met as evidenced by:
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The ED agreed to do the following:
1. Repair or replace the screen on the window no later than 1/24/2023.
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Based on observation, the licensee did not comply with the section cited above, as the window screen in the theater room was missing, which poses an immediate health and safety 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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3