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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 03/01/2023
Date Signed: 03/01/2023 03:10:06 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
12/27/2021 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20211227152245
FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:GUTIERREZ, SARAFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 48DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Cynthia GarciaTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff are not providing adequate food service to resident's
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver the findings to the above facility. LPA met with Business Office Manager (BOM) Cynthia Garcia at 9:15 a.m. Entrance interview conducted.

On 12/27/2021, the Department (RO) received a complaint regarding staff are not providing adequate food service to residents. Interview with Resident #1 (R1) on 01/03/2022, starting at 1:23 p.m. , on 10/13/2022, starting at 1:20 p.m. and on 01/04/2023, starting at 12:10 p.m., revealed that there have been various times that food was not delivered on time. R1 stated that on 12/25/2021, no staff came to escort R1 to the dining room for dinner. Additionally, R1 stated there have been times that they eat in their rooms only to have the dining room staff forget an essential item like coffee, butter, and silverware. Lastly, R1 added that on 01/22/2023, R1 and all the residents at the facility received their breakfast one (1) hour after the allotted time of 8:00 – 9:30 a.m.
Continued on LIC 9099 - C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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-20211227152245
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: 03/01/2023
NARRATIVE
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Two (2) resident interviews on 01/24/2023 with LPA Ashley Morgan confirmed what R1 had stated regarding breakfast arriving late on 01/22/2023. Interviews with eleven (11) residents on 10/13/2022, 01/04/2023, 01/23/2023, and 02/22/2023 revealed that although the facility does provide meals, the food being served is not of best quantity and quality. Additionally, staff often forgets utensils and condiments that go with the meal, thus, delaying residents’ food. Additionally, when the food is delivered to the resident’s room, most of the time, the meals arrive late and cold.

Although interviews with resident stated that the food service was decent on some days, the majority of resident interviews stated they are unhappy with food services as their food often arrives late, cold, has missing items or utensils and may not be edible at times. Based on interviews and observation, the allegation of staff is not providing adequate food service to residents is deemed substantiated at this time.

A similar complaint was substantiated on 02/22/23.

1 citation was issued. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).

Exit interview conducted and a copy of the report and appeal right were issued to BOM.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20211227152245
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: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (a)(4) Residents … shall have ... the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency ...This requirement is not met as evidenced by:
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BOM stated they will create a plan for food services that maintains compliance with regulations and personal rights. BOM will deliver plan to LPA by 3/17/23.
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Based on interviews and evidence gathered throughout the investigation, the licensee did not comply with the section cited above as various residents stated that food service is inadequate which poses a potential health, safety and personal rights risk to residents on 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 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
12/27/2021 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20211227152245

FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:GUTIERREZ, SARAFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 48DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Cynthia GarciaTIME COMPLETED:
03:20 PM
ALLEGATION(S):
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2
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9
Staff did not administer resident's medication in a timely manner
Staff did not administer resident's medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver the findings to the above facility. LPA met with Business Office Manager (BOM) Cynthia Garcia at 9:15 a.m. Entrance interview conducted.

On 12/27/2021, the Department (RO) received a complaint regarding staff did not administer resident's medication in a timely manner and staff did not administer resident's medication. Interview with Resident #1 (R1) on 01/03/2022, starting at 1:20 p.m. , revealed that because R1 takes their own blood pressure daily, R1 noticed that on 12/15/2021, blood pressure was higher than normal despite taking a routine high blood pressure medication. R1 stated they spoke to a staff member regarding a medication R1 needed to take. R1 continued, the staff member refused to give R1 the medication stating R1 takes routine medication for high blood pressure, but R1 was asking for a Pro Re Nata (PRN) medication. R1 stated, after a short while, the staff member returned with the PRN medication. R1 added that the staff member needed to get clarification from the nurse at the facility. Continued on LIC 9099 - C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20211227152245
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: 03/01/2023
NARRATIVE
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That same day, interview with the Resident Care Coordinator (RCC), starting at 12:43 p.m. revealed the medication training and process for all medication technicians at the facility. Additionally, the RCC added that a staff member approached them regarding R1’s PRN medication on 12/15/2021. RCC stated that after a while, the staff left the RCC’s office to give medication to R1. Interview with R1’s family member on 01/06/2022, starting at 3:07 p.m. confirmed what R1 stated as R1’s family member was present during the situation.

Review of R1’s medical file on 03/01/2023 revealed that a clarification form was sent and signed on 06/18/2019, from Pacifica Senior Living Oxnard to R1’s Medical Doctor (MD) regarding the approval of the self-administration of medication, in addition, for R1 to take their own blood pressure and to inform staff if any medication is needed. A review of R1’s Medication Administration Record (MAR) revealed two (2) daily routine high blood pressure medications were self-administered on 12/15/2021, as well as a resident request PRN high blood pressure medication was self-administered that same day, at 4:43 p.m.

Interviews with five (5) residents 02/22/2023 and 03/01/2023, revealed that residents have not had any problems with requesting additional medication if needed, they have not been refused medication and staff are tentative with their medication needs.

Although R1 stated the staff member refused to give R1 additional blood pressure medication, R1’s MAR indicated that R1 received their daily routine blood pressure medication in a timely manner. Additionally, the MAR revealed that one (1) as needed blood pressure medication was requested and self-administer the same day based on MD orders. Based on interviews and record review, the allegation of staff did not assist with the self-administration of medication in a timely manner is deemed unsubstantiated at this time.

A similar complaint was Unsubstantiated on 09/23/2022.

Regarding staff did not help with the self-administration of resident's medication. Interview with Resident #1 (R1) on 01/03/2022, starting at 1:20 p.m. , revealed that R1 takes their own blood pressure daily based on MD orders. On 12/15/2021, blood pressure was higher than normal and requested additional medication. R1 stated they spoke to a staff member who refused to give R1 medication. R1 added that they eventually received help with the self-administration of medication. Review of R1’s MAR for the month of December 2021, revealed that R1 did received assistance with the self-administration of medication as prescribed by their MD. Additionally, R1 received help with the self-administration of 6 PRN medications for December 2021. Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20211227152245
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: 03/01/2023
NARRATIVE
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Interview with five (5) residents 02/22/2023 and 03/01/2023, revealed that some residents self-manage their own medication, while other resident obtain help with the self-administration of medication at the facility on a daily basis.

Although R1 stated the staff member refused to give R1 additional blood pressure medication, R1’s MAR indicated that R1 received help with the self-administration of medication for the entire month of December 2021 based on MD orders. Based on interviews and record review, the allegation of staff did not help with the self-administration of medication is deemed unsubstantiated at this time.

Exit interview conducted and copy of the report was issued to the BOM.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6