565802425-10-7-2021-31-AS-KHEN-C8A227-20211029170014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 10/06/2021
Date Signed: 10/07/2021 09:49:30 AM

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
03/23/2020 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 31-AS-20200323142453

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: 51	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	10:19 AM
MET WITH:	Cynthia Garcia		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegation. LPA Ascencio met with Business Office Manager, Cynthia Garcia at 10:19 a.m. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 03/23/2020, alleging that a resident sustained unexplained injuries while in care. During the course of the investigation, LPA Ascencio conducted interviews with staff, residents, responsible parties, and outside agencies on 10/20/2020, 12/10/2020, 08/12/2021 and 10/06/2021. On 10/06/2021, LPA also reviewed facility files and obtained pertinent documents.

Continued on LIC - 9099-C

Unsubstantiated

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: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200323142453

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: 10/06/2021

NARRATIVE

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Interviews stated that resident #1 (R1) had a fall on or around 03/23/2020. File review on 10/06/2021 revealed that R1 had fallen on 03/21/2020 in the afternoon shift. R1 was getting up from the couch in the living room. File review and interviews also confirmed R1 was receiving hospice services before the fall. R1 had a hospice diagnosis of Alzheimer’s Disease unspecified. Facility staff immediately called hospice agency to report and monitor R1. R1 was regularly monitored and seen by a hospice nurse 2-3 times a week. Interview with R1 could not be conducted as they passed on 09/20/2020. On 08/12/2021, LPA obtained photographs of R1 from facility file between the dates of 03/23/2020 and 03/30/2020, which revealed puffiness and yellow, green, red and purple discoloration on the right side of the face above and below eye. Interview on 08/12/2021 with staff #1 (S1) revealed that R1 would often wear non-fitting clothing thus causing R1 to stumble. Review of R1’s facility file and chart notes revealed that following the fall, R1 was placed on hourly checks and was given as needed medication for pain management. Review of R1’s hospice notes on 10/06/2021 confirmed R1’s fall on 03/21/2020 and hospice visit on day of and days following of fall. Hospice note on 03/30/2020 states that “R1 continues to walk wit eyes closed and needs constant redirection.”

Based on the evidence gathered, there is insufficient evidence to prove the alleged violation occurred due to staff neglect and lack of supervision. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. A copy of this report provided to BOM via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

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