565802425-10-25-2022-29-AS-JAPL-CSBVGZ-20230530162615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 10/25/2022
Date Signed: 10/25/2022 06:33:22 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: 52	DATE:	10/25/2022
		UNANNOUNCED	TIME BEGAN:	12:24 PM
MET WITH:	Kortnie Spitznogle		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Staff did not respond to resident's calls for assistance.
Staff are not providing residents with food of good quality.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to the above facility. LPA met with Executive Director Kortnie Spitznogle at 12:35 p.m. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 10/12/2022 regarding staff did not respond to residents's calls for assist and staff are not providing residents with food of good quality. During Resident #1 (R1) interview on 10/13/2022 starting at 3:06 p.m., R1 stated that their pendant was not working for awhile and that it took about thirty (30) minutes for a staff member to respond. R1 added they had a wrist bracelet but was changed to an necklace pendant. R1 also added that the average time to wait for care staff to assist them was about ffteen (15) - twenty (20) minutes long. R1 added, there was once incident in early October that R1 had to urinate but staff never showed up. R1 had an incontinence accident on this occacion. On 10/25/2022, starting at 3:02 p.m., LPA reviewed the SMARTcare Alert Call Button report for R1.

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: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

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 4

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: 10/25/2022

NARRATIVE

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Review of the SMARTcare Report revealed from 09/7/2022 through 09/30/2022 there was fifty (50) alert button announcements that had elapsed the companies fifteen (15) minute policy. Further review of the SMARcare report also revealed that there was eleven (11) alerts that were never responded to the time frame of 09/7/2022 - 09/30/2022. Based on record review and interview, the allegation is substantiated at this time.

Regarding the allegation of Staff are not providing residents with food of good quality. Interview with three (3) residents on 10/13/2022 starting at 3:20 p.m., one (1) resident on 10/18/2022 starting at 8:11 a.m., and three (3) resident on 10/25/2022 starting at 2:50 p.m., it was revealed that the food is not great. Residents added that the meals are not consistent with variety and with no consideration to the age group being served. Residents also said that the quality and quantity of food doesn't meet up to the standards of what the resident should be having. Residents stated they have been served, corndogs, sandwiches, stale bread with their hamburgers, burnt beans, uncooked meat, uncooked pancakes, frozen meats, chili beans and Dorito floats. Several residents had taken pictures of the various meals that have been served and sent LPA a copy of the pictures. Interview with four (4) staff on 10/13/2022, 10/19/2022, and 10/25/2022 revealed that the food is horrible here. Staff stated what is on the menu is different from what they are receiving. There has been various complaint about food and some resident get upset because they don't have it. Staff included that there are some residents that are refusing to eat in the dinning room because the food being served is not of food quality. Staff provided LPA with photographs of meals being served to residents that included burn beans, corn dogs, onion rings, and crushed-up Doritos on a plate with meat. Review of Staff #1(S1) files revealed that S1 has been the head cook since August 2022. S1 was hired in June 2022 initially as the Activities Director but was promoted to Dinning Service Director. LPA noted that S1 had previously worked as a prep-cook at another assisted facility. LPA requested and received the required annual training for S1 but had no qualified formal training in dinning services. Based on record review, interviews and observation, the allegation, staff are not providing residents with food of good quality is deemed substantiated at this time.

2 citations were issued during today's visit. 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, today's report and appeal rights were reviewed and emailed to ED.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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: 10/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/04/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Admin will provide training on Personal Rights and Process and Procedure on the call monitoring system for time effeciency to staff. Admin will provide copy of training material and staff attendees to LPA via email. angel.ascencio@dss.ca.gov
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee did not comly with the section cited above the staff did not respond to resident's calls for assistance which poses a potential health, safety and personal risk to persons in care.	8 9 10 11 12 13 14
Type B 11/04/2022 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	87555 General Food Service Requirments (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.	1 2 3 4 5 6 7	Admin will conduct ongoing, monthly meetings with the residents to address the quality of food When foods items are not accesible, Admin will delegate with coorporate to find other healthier and alternatives foods for residents. Admin will provide an updated menu to LPA with healthier, viarety choice of foods.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, record review and observation, the licensee did not comply with the section cited above as the facility has not been meeting the needs of the residents in quality and quantity which poses a potentail health, safety and personal rights risk to person in care.	8 9 10 11 12 13 14

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: 10/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC9099 (FAS) - (06/04)

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