565802425-8-17-2021-31-AS-KHEN-C67W2D-20210824165410

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 08/12/2021
Date Signed: 08/17/2021 12:04:23 PM

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
10/02/2019 and conducted by Evaluator Angel Ascencio

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20191002133729

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:	11:20 AM

ALLEGATION(S):

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Severe neglect resulting in death of resident.
Resident sustained a fracture while in care.
Resident's left in soiled clothing for a long period of time.
Resident's room is unsanitary.
Facility has a foul odor.
Staff failed to meet resident's hygiene needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) JoAnn Rosales conducted an unannounced subsequent complaint visit to the above facility to amend technical errors on page 2 of complaint investigation report issued on 8/12/21.

It was alleged that severe neglect resulted in the death of Resident #1 (R1). It was further reported that on 09/27/2019, R1 was found deceased in R1s bedroom after sustaining a fall and hitting R1s head.

During the course of the investigation, interviews were conducted with S3 and S4 on 10/3/19 starting at 1:47 pm and Hospice Aide on 10/3/19 at 10:57 am. In addition, LPA obtained and reviewed facility documentation pertinent to the allegations on 10/3/19. LPA also obtained and reviewed Hospice documentation on 10/9/19.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

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 3

Control Number 31-AS-20191002133729

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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Interviews conducted and documents reviewed reflected that on 9/27/19 starting at 1:15 pm, R1 was assessed by Hospice staff and a significant decline was noted. R1 slept the entire visit. On 09/27/2019, R1 was found on the floor inside R1s bedroom by staff at around 10 pm. Staff did not observe any blood. Staff observed R1s head leaning upright beside their bedrail. Staff assessed R1 and asked if R1 was in pain and R1 stated “no”. R1 was placed back in bed by staff. R1s hospice agency was contacted at 10:38 pm. On 9/28/19 at 3:08 am staff called to report R1 passed away. R1’s certificate of death indicates immediate cause of death as congestive heart failure and hypertension.

Based on all information gathered, the above allegation, “severe neglect resulting in death of resident #1 (R1)” is deemed unsubstantiated at this time.

An additional concern was that R2 sustained a fracture while in care on 10/1/19 due to shortage in staff. A review of R2s records on revealed that on 9/30/19, R2 was found on the floor outside of the bathroom during room check at 9:50 pm complaining of pain and was sent out 911. Interview with S12 on 6/5/2020 at 11:37 am revealed that residents are checked every 2-hours and R2 was found on the floor in their room during room checks. S12 indicated that they had sufficient staffing that night to meet the resident’s needs. Interview with S14 on 7/20/2020 at 1:36 pm revealed that R2 was found on the floor while staff were during their final rounds. S14 stated that R2 had an unwitnessed fall.

Based on all information gathered, the above allegation, “Resident #2 (R2) sustained a fracture while in care” is deemed unsubstantiated at this time.

Another allegation is that R3’s room is unsanitary as R3’s room has feces inside of it with trash bin overflowing with toilet paper with feces on it therefore, causing a foul odor in the hallway outside of R3’s room.

Interview with S1 and S2 on 10/3/19 starting at 9:51 am revealed that R3 needs special attention and staff are aware of R3’s hygiene issues. Interview with S14 on 7/20/2020 at 1:36 pm revealed that R3 would change themselves without letting staff know and would leave their depends under their bed. S14 stated that they would clean them up when they found them. S14 stated that the housekeepers would clean R3’s room daily. Interview with S2 on 10/3/19 at 1:28 pm revealed that R3s room is cleaned every other day or sooner if needed.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20191002133729

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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During facility tour on 10/3/19, LPA did not observe a foul odor in the hallway outside of R3’s room, nor did LPA did observe R3’s room unsanitary with feces.

Based on all information gathered, the above allegations, “Resident #3 (R3) room is unsanitary and is causing a foul odor in the hallway” are deemed unsubstantiated at this time.

It was also alleged the facility failed to meet R3’s hygiene needs, as R3 had been covered in urine and feces. Written statement received from S5 on 11/22/19, revealed that if R3 was observed with feces, staff would shower R3 and any soiled clothing or linens were always taken to be washed. Interview with S14 revealed that R3 would not let care staff assist them and was non-complaint. Written statement received from S6 on 11/16/19, revealed that R3 was checked every 2-hours during the NOC shift and was observed to be removing their diaper, even when dry. A review of R3’s records on revealed that on 10/2/19, care staff responded to R3’s request for assistance and R3 was observed with feces on them. R3 was showered and R3’s room was thoroughly cleaned. R3’s Needs and Services Assessment indicates R3 requires a 2-person assist for bathing twice a week. R3 only requires grooming and dressing reminders. Toileting – cueing as R3 hides fecal matter and soiled toilet paper.

Based on all information gathered, the above allegation, “Staff failed to meet resident #3 (R3) hygiene needs” is deemed unsubstantiated at this time.

Copy of the report to be provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021

LIC9099 (FAS) - (06/04)

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