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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:27:45 PM


Document Has Been Signed on 04/21/2023 03:27 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: 56DATE:
04/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit regarding an incident which took place on 4/10/2023 in which resident 1 (R1) left the facility without being accompanied by staff. R1 was later found by police at approximately 2:00 p.m., confused and lost. The police brought R1 back to the facility the same day.

LPA met with administrator/executive director Elizabeth Whittington at 10:25 a.m. LPA reviewed and obtained pertinent records at 12:40 p.m. LPA interviewed staff 1 (S1) at 12:30 p.m.

LPA's review of records showed the facility has a physician's report on file for R1 which states R1 cannot leave the facility unassisted.

S1 stated the facility receptionist has a list of residents who are not allowed to leave the facility unassisted. The facility has a "Resident Sign Out/In Log" and it is their policy for all residents to use this log when they leave the facility and return. When a resident is signing out the receptionist is to confirm the resident is allowed to leave the facility without assistance from staff.

LPA Camara reviewed the "Resident Sign Out/In Log" for 04/08/2023 - 04/15/2023 and observed R1 signed out on 4/8/2023 at 2:13 p.m., 4/9/2023 1:37 p.m. and 4/10/2023 at 1:02 p.m. Each time stating they were going to Walmart.

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 was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2023 03:27 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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited

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87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic
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Administrator will immediately ensure staff do not allow residents who need assistance to leave the facility without such assistance. In addition, administrator will provide evidence of training caregivers and receptionists regarding these policies to CCL on or before 4/28/2023.
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services specified below, either directly or through outside resources.
This requirement is not met as evidenced by:
Based on interviews and record review, the licensee did not comply with the section cited above, as staff were aware R1 was not to leave the facility unassisted but failed to ensure R1 had assistance when they
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signed out to leave the facility on 4/8,9&10/2023, which poses an immediate health and safety risk to persons 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: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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