565802425-8-31-2022-29-AS-DPEA-CNKTS8-20230130135843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 08/31/2022
Date Signed: 08/31/2022 04:30:28 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
06/07/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20220607135730

FACILITY NAME:	PACIFICA SENIOR LIVING OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	KORTNIE SPITZNOGLE		FACILITY TYPE:	740
ADDRESS:	2211 E GONZALES RD		TELEPHONE:	(805) 983-6808
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	100	CENSUS: 49	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	03:37 PM
MET WITH:	Kortnie Spitznogle, Administrator		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Insufficient staffing
Resident's incontinence needs not being met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi, conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 3:37 p.m., the LPA met with Administrator, Kortnie Spitznogle and explained the reason for the visit.

During the initial visit on 06/14/2022, LPAs Emily Peraldi and Zabel Chochian interviewed the Administrator, requested and reviewed pertinent documents between 10:50 a.m. and 1:25 p.m. Additionally, on 06/14/2022, LPA Peraldi and the Administrator conducted a physical plant tour and LPA Peraldi interviewed six (6) out of fifty-three (53) residents and staff between 1:24 p.m. and 3:25 p.m. On 06/24/2022, LPA Peraldi conducted an interview with hospice nurse. In addition, LPA Peraldi subpoenaed hospice agency records and reviewed documents pertinent to the case on 08/04/2022. Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

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-20220607135730

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: 08/31/2022

NARRATIVE

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Regarding the allegation: Insufficient staffing.
It was alleged that at the time the complaint was received, the facility had insufficient staffing due to staff quitting. Interview with Administrator on 06/14/2022, revealed that direct care staff/caregivers often call off or quit. Since direct care staff/caregivers call off or quit, it leads to the Administrator and other Administrative staff covering as caregivers, cooks and bus drivers. The Administrator stated that the Dining Service Director quit on the spot on 05/29/2022, which the Administrator began to act as a cook once a week until the replacement was found on 07/01/2022. The LPAs emphasized that due to the Administrator stepping in and acting as a direct care staff that it takes time away from completing Administrator duties. The Administrator explained that the facility is currently hiring, but the hiring process and training process is not fast enough. Additionally, four (4) out of six (6) residents interviewed on 06/14/2022, stated that the facility is short staffed and that the facility needs more staff. The resident interviews also revealed that the shortage in staffing is causing a delay in getting to the residents on time and meeting the resident’s needs. Staff interview on 06/14/2022, also confirmed the facility has a shortage in staffing and that direct care staff often work one (1) week and quit. Record review conducted on 06/14/2022 of staff schedules for June 2022, confirmed that staff often call off or quit since some shifts are crossed off or staff names are completely crossed off. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Regarding the allegation: Resident's incontinence needs not being met
It was alleged that the facility staff did not meet Resident #1 (R1) incontinence needs. Interview with Administrator on 06/14/2022, revealed that the facility staff check on and reposition R1 every 2 hours per shift since R1 was bedridden. During the physical plant tour on 06/14/2022, LPA Peraldi observed a Two (2) Hour Reposition Log and a Bowel Movement Log for June 2022 taped onto R1’s wall near R1’s bed. The Two (2) Hour Reposition Log had missing dates or incomplete dates on 06/03/2022, 06/04/2022, 06/05/2022 and 06/06/2022. Additionally, on 08/04/2022, LPA Peraldi reviewed R1’s hospice records. Hospice records revealed that on 06/06/2022 hospice nurse found R1 saturated in urine, dry stool in groin area, and stool under draw sheet. Interview with hospice nurse conducted on 06/24/2022, confirmed that R1 was found saturated in urine and stool. Based on record review and interview, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220607135730

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: 08/31/2022

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	Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited: (Refer to LIC 9099-D). Exit interview conducted with Administrator. A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20220607135730

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: 08/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/01/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a)Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Submit a Staffing Plan to CCL and updated schedule by 09/01/2022.
	8 9 10 11 12 13 14	Based on interviews and record review, licensee failed to ensure that the facility had an adequate number of staff to meet the residents needs, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 09/01/2022 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	87625(b)(3)Managed Incontinence (b)General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: Submit a plan of action of how staff manages residents incontinence needs to CCL no later than 09/01/2022.
	8 9 10 11 12 13 14	Based on interview and record review, licensee failed to ensure/meet R1’s incontinence needs which led to R1 being found not clean and dry, which poses an immediate health and safety risk to residents 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 Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

Page: 4 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
06/07/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20220607135730

FACILITY NAME:	PACIFICA SENIOR LIVING OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	KORTNIE SPITZNOGLE		FACILITY TYPE:	740
ADDRESS:	2211 E GONZALES RD		TELEPHONE:	(805) 983-6808
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	100	CENSUS: 49	DATE:	08/31/2022
		UNANNOUNCED	TIME BEGAN:	03:37 PM
MET WITH:	Kortnie Spitznogle, Administrator		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff did not provide resident with clean linens

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20220607135730

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: 08/31/2022

NARRATIVE

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Regarding the allegation: Staff did not provide resident with clean linens.
It was alleged that the facility does not clean residents’ linens. Interview with Administrator on 06/14/2022, revealed that the facility does not provide linens to residents upon admission and the residents bring their own linens. The Administrator explained that once residents are moved in and have linens, the facility does wash them. The Administrator stated that the facility does wash resident’s linens weekly and ensures that residents have clean linens. Interviews with staff and residents on 06/14/2022, confirmed that the facility does laundry once a week. None of the six (6) residents interviewed complained about the laundry services or about the uncleaned linens. During the physical plant tour on 06/14/2022, LPA Peraldi did not observe dirty or uncleaned linens. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted with Administrator. A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022

LIC9099 (FAS) - (06/04)

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