565802425-5-2-2023-29-AS-JAPL-CSBVGX-20230530162614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 05/02/2023
Date Signed: 05/02/2023 04:29:09 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
10/12/2022 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20221012131509

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: 56	DATE:	05/02/2023
		UNANNOUNCED	TIME BEGAN:	11:58 AM
MET WITH:	Elizabeth Whittington		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Resident experiencing numerous falls and injury(ries) at facility due to lack of supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to the above facility. LPA Ascencio met with Executive Director(ED) Elizabeth Whittington at 12:10 p.m. Entrance interview conducted.

On 10/12/2022, the Department (RO) received a complaint regarding resident experiencing numerous falls and injury(ries) at facility due to lack of supervision. Interview with Executive Director (ED) Kortnie Spitznogle on 10/13/2022, starting at 1:16 p.m. revealed that Resident #1 (R1) moved into the facility on October 3th, 2022 after being discharged from a skilled nursing facility. The following day, R1 had a fall and went to the hospital and did not return. ED Spitznogle stated that during resident assessment, there was no concern for R1, but was very unhappy, depressed, and withdrawn.

Continued on LIC 9099 - C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

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 5

Control Number 29-AS-20221012131509

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: 05/02/2023

NARRATIVE

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Interview with Staff #1 (S1) on 03/07/2023 at 10:47 a.m., and 03/09/2023 at 12:45 p.m. confirmed R1’s singular fall and mental state. Additional staff interviews on 10/12/2022, and 03/07/2023 revealed that R1 had three (3) falls on 10/04/2022. Staff stated only two (2) staff members were working that day and they helped assist R1 to their bed after two falls. After assisting R1, staff indicated they verbally let the medication technician know what happened. Further staff interviews revealed that on R1’ s 3^rd fall, 911 was contacted, and R1 was sent out to the hospital and was admitted that same day. Staff interviews also confirmed R1 did not come back to Pacifica after being hospitalized. Staff interviews also indicated that when a resident has a fall, the medication technician is notified, assess the resident and notifies the Executive Director and management of the fall. Lastly, staff indicated that they are unsure if the two (2) falls were reported to management but, on the 3^rd fall, R1 was sent out to hospital. Although ED Spitznogle and staff stated only one (1) fall was recorded and reported, additional staff interviews confirmed that on 10/04/2022, multiple staff observed R1, on 3 separate occasions, on the floor from a fall.

LPA Ascencio reviewed the Incident Report for R1 dated 10/04/2022, which indicated 1 fall occurred. Additionally, a narrative charting entry and a physician commutation form was observed, both indicating that R1 had one (1) fall on 10/04/2022. Review of R1’s medical records on 03/01/2023, revealed R1’s diagnosis of sepsis, difficulty walking, muscle weakness, age-related physical disabilities, and ten (10) other medical diagnoses, according to the Physicians Report. Additionally, the Physician’s Report also indicates R1 was able to bathe, dress/groom, feed self and able to care for own toileting needs with minimal assistance. Lastly, R1’s facility assessment indicates bathing, dressing, transfer, toileting and escort require total assist from Pacifica staff.

Even though, R1’s physician report indicated minimal assist with activities of daily living (ADL), Pacifica’s plan of care indicates R1 depends on staff assistance for all ADLs. R1’s discharged document, dated 09/27/2022, from a skilled nursing facility (SNF) indicated that R1 had multiple falls and was considered a fall risk. Therefore, due to R1’s facility assessment indicating total assistance with ADLs, knowledge of R1 being a fall risk from documentation, and multiple staff admitting that R1 had three (3) falls on 10/04/2022, R1 sustained multiple falls at the facility based on lack of care and supervision. Based on evidence gathered, there is sufficient evidence to support the allegation of resident experiencing numerous falls and injury(ries) at facility due to lack of supervision. Thus, the allegation is substantiated at this time.

Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20221012131509

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: 05/02/2023

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	A similar complaint was substantiated on 05/24/2022. An immediate civil penalty of $1,000.00 was assessed on 05/02/2023 due to repeat violation. 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 copy of the report and appeal rights were issued to ED.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20221012131509

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: 05/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/03/2023 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2 This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated they will conduct training on care and supervision to provide basics services. Administrator will provide copies to LPA via email by 5/12/23.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section cited above as the licensee did not provide adequate care and supervision or seek higher level of care to R1 which attributed to R1 sustaining multiple falls within 1 day which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

LIC9099 (FAS) - (06/04)

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