565802425-3-9-2023-29-AS-JAPL-CSBVGY-20230530162614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 03/09/2023
Date Signed: 03/09/2023 03:58:11 PM

Unsubstantiated

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: 48	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	11:28 AM
MET WITH:	Jade Alma		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Resident’s room has mold.

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 Interim Executive Director (ED) Jade Alma at 11:28 a.m. Entrance interview conducted.

On 10/12/2022, the Department (RO) received a complaint regarding resident’s room had mold. Interview with Executive Director (ED) Kortnie Spitznogle on 10/13/2022, starting at 1:16 p.m. revealed that staff reported to ED Spitznogle regarding possible mold in Resident #1’s (R1) room. ED Spitznogle stated the ED and an Interim Maintenance Director looked at R1’s room and could not identify the type of stains in R1’s apartment wall. ED Spitznogle purchased cleaning solution and paint to fix the issue. Additionally, ED Spitznogle added that there was a room upstairs that they found was leaking water, which was fixed. Later that same day, interview with R1, starting at 4:10 p.m. confirmed what ED Spitznogle stated and, according to R1, believed it was mold on the wall but was unsure.
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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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 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: 03/09/2023

NARRATIVE

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LPA Ascencio observed R1’s private apartment on 10/12/2022, 10/25/2022, and 02/22/2023 which revealed that the south side apartment wall has visible water stains marking's that have been painted over. Additionally, on 02/22/2023, LPA Ascencio, LPA Ashley Morgan and LPA Esther Cortez walked into a housekeeping closet adjacent to R1’s apartment, and three (3) residents’ room above R1’s apartment and did not observe any water leaks or mold that could have affected R1’s apartment walls. Although interviews with R1 and ED Spitznogle stated they were unsure the stains in R1’s apartment wall was mold, it was revealed that the walls were cleaned, treated and painted for preventative measures but, the south wall has visible stain marking's that are unknown whether they are mold or water damage.

On 02/22/2023 and on 03/09/2023, in the common area, next to the dinning room, there is a large, discolored corner area that looks like water damage. LPA Ascencio spoke with the Interim ED regarding R1’s visible stains and possible water damage in the common area. Interim ED stated the currently don’t have a Maintenance Director but will hire and a professional to look at R1’s room and the water damage in the common area.

Based on the information obtained, there is insufficient evidence to support the claim that resident’s room has mold. Thus, the allegation above is deemed Unsubstantiated at this time.

Exit interview conducted and copy of the report was issued to business Office Manager and Interim ED.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

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