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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 02/22/2023
Date Signed: 02/22/2023 03:37:43 PM


Document Has Been Signed on 02/22/2023 03:37 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: 47DATE:
02/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cynthia Garcia, Business Office ManagerTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ashley Smith, Esther Cortez, 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-20230123143000.

At 11:06 a.m., the office to the Activities Director was unlocked. In the room, the LPAs observed accessible alcohol, cleaning supplies (disinfectant wipes), personal care items (shampoo, soap), and scissors.

At 12:10 p.m., the LPAs were touring the memory care unit, and observed sand bags blocking the entrance into the courtyard. The LPAs were able to enter the courtyard; however, the attempted to leave the enclosed courtyard in the memory care unit and discovered that the LPAs was 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. The LPA has discussed this concern with the Executive Director on 1/23/2023 and 2/15/2023. Civil penalties assessed in the amount of $250 for a repeat violation.

At 12:18 p.m., the LPAs were touring a resident room in the memory care unit. The LPAs observed accessible Lysol spray and Clorox wipes in the resident bathroom cabinet.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
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 2


Document Has Been Signed on 02/22/2023 03:37 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: 02/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2023
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 staff agreed to do the following:
1. Ensure the doors are unlocked by the end of the day.
2. Document how the community will regain compliance with Regulation 87468.1(a)(6). Inform CCL when this has taken place, no later than 2/27/2023, end of day.
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Based on observation, the licensee did not comply with the section cited above, as the doors to the courtyard in the dementia unit are locked from the inside, thus prohibiting a resident from going into the facility if they're in the courtyard, which poses an immediate personal rights risk to residents in care.
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This is a repeat violation; civil penalty assessed in the amount of $250.
Type A
02/23/2023
Section Cited

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87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible ... : Over-the-counter medication ... or, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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The staff agreed to do the following:
1. Items were secured upon observation. Staff agreed to provide training regarding regulation 87705(f)(2). Submit sign in sheet no later than 2/27/2023.
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Based on observations, the licensee did not comply with the section cited above as alcohol and cleaning supplies were accessible to residents, which poses an immediate health and safety risk to persons in care.
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This is a repeat violation; civil penalty assessed in the amount of $250.
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: 02/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2023
LIC809 (FAS) - (06/04)
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