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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 05/19/2023
Date Signed: 05/19/2023 03:41:26 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 OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:KORTNIE SPITZNOGLEFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 44DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff did not administer resident’s medication as needed
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 Elizabeth Whittington at 9:20 a.m. Entrance interview conducted.

On 10/12/2022, the Department (RO) received a complaint alleging that there has been various occasion that staff did not administer resident’s medication as needed. On 01/23/2023, interview with R1 revealed there was only one (1) instance R1’s blood pressure medication was given late. R1 was out of the facility with family and upon R1’s return, their blood pressure was high. R1 requested medication from the medication technician (med tech) and initially refused to give R1 their blood pressure medication but after some time, the med tech gave R1 the medication. Otherwise, R1 stated there has not been any other medication incidents since December 2021.

Continued on LIC 9099 - C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
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 8
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: 05/19/2023
NARRATIVE
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A file review for R1 was conducted on 03/01/2023, which revealed that R1 can do their own blood pressure and request for medication to self-administer medication. At the time of the file review, R1 has an as need (PRN) medication for blood pressure medication. Additionally, interviews with various residents on 02/22/2023, 03/01/2023, and 05/05/2023 revealed that they have not had any problems with medication, requesting medication or a lapse in medication.

However, LPA Ascencio, LPA Ashley Morgan and LPA Elsie Campos conducted a medication audit on 05/19/2023, starting at 12:00 p.m. revealed that two (2) residents (which included an audit of R2’s medications) did not have their “as needed” medication at the facility specific for blood pressure. Due to this, if R1 requested additional blood pressure medication, the facility would not be able to assist R1 with their blood pressure medication. Thus, based on evidence gathered, the allegation of staff did not administer medication as needed is substantiated at this time.

The following deficiencies were observed (See LIC 9909-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties

Exit interview conducted and a copy of the report and appeal rights were issued to ED.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2023
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a)(4)A plan for incidental medical and dental care shall be developed by each facility... The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Administrator will conduct Med Audit for all PRN meds in 2 days. Administrator will submit a plan on how to obtain PRN medication for R1 and R2 and submit by 05/22/2023.
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Based on a medication audit, the licensee did not comply with the section cited above as R1 and R2 did not have their PRN blood pressure medication at the facility which staff cannot assist residents with self-adminsitration of medication which poses an immidiate health and safetey risk to resident 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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 OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:KORTNIE SPITZNOGLEFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 44DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Resident sustained a bladder inection and an uti in care of facility staff
Staff did not seek timely medical attention for resident.
Staff did not properly prepare food in result of resident getting food poisoning.
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 Elizabeth Whittington at 9:20 a.m. Entrance interview conducted.

On 10/12/2022, the Department (RO) received a complaint regarding resident sustained a bladder infection and a urinary tract infection (UTI) while in care of facility staff, staff did not seek timely medical attention for resident, staff did not administer resident’s medication as needed and staff did not properly prepare food in result of resident getting food poisoning. Interview with Executive Director (ED) Kortnie Spitznogle on 10/13/2022, starting at 1:16 p.m. and on 01/04/2023 starting at 12:25 pm, revealed that Resident #1 (R1) was considered independent and did not require any staff assistance with activities of daily living (ALD). ED Spitznogle added that R1 started presenting with unusual behaviors such as staying in bed and not wanting to eat causing various incidents between August 2022 and October 2022.
Continued on LIC 9099 - C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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: 05/19/2023
NARRATIVE
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Additionally, ED Spitznogle stated that staff reported R1 having very frequent incontinence issues while being in bed. On 10/06/2022, R1 was sent out to be evaluated. On 10/16/2022, R1 returned to the facility with tubes in their back and a diagnosis of Acute Renal Failure. According to the Mayo Clinic, “Acute kidney failure — also called acute renal failure - occurs when your kidneys suddenly become unable to filter waste products from your blood.” ED Spitznogle added that R1 was sent out to the hospital on 10/23/2022 because R1 had pulled their tubes out of their body. R1 was admitted to the hospital, then transferred to a skilled nursing facility (SNF) and was re-admitted to Pacifica Senior Living on 12/02/2022. On 12/19/2022, R1 had an unwitnessed fall, was sent out to the hospital and did not return to the facility. Staff interviews on 10/12/2022, and 03/07/2023 confirmed what ED Spitznogle stated. Additionally, staff stated that R1 would request assistance from the care staff who would assist R1 in their incontinence needs. Lastly, staff indicated that staff would constantly give R1 water as staff were aware of R1’s diagnosis. Although R1 was considered independent, an apparent change in condition in R1 caused facility staff to be proactive and seek medical attention while addressing his needs due to his diagnosis.

On 10/13/2022, 03/09/2023 and 05/02/2023, a file review on R1 was conducted confirming what ED Spitznogle and staff stated. Additionally, R1’s file review indicated that R1 moved into Pacifica Senior Living Oxnard on 02/12/2022, uses a wheelchair or walker to ambulate within the facility, required minimal assistance with transfers, dressing, bathing, grooming, and required no assistance with eating, toileting and managing cash resources. R1’s Physician’s Report indicated that R1 had a diagnosis of chronic kidney disease (stage 2) and seven (7) other conditions. According to the Mayo Clinic, your kidneys filter wastes and excess fluids from your blood, which are then removed in your urine. Advanced chronic kidney disease can cause dangerous levels of fluid, electrolytes and wastes to build up in your body. Further file review for R1 revealed four (4) Internal Incident Reports and Narrative Charting notes indicating R1’s incidents and staff seeking medical attention, confirming what ED Spitznogle and staff stated. Lastly, hospital discharge documents and hospital charting notes, dating 10/19/2022, confirmed R1’s primary diagnosis of chronic kidney disease as well as notes stating R1 “started on antibiotics due to a UTI, although test done did not indicate infection” and “unclear if active infection for UTI.”

Even though R1 was independent, staff interviews indicated that R1 had a change in condition and depended on staff assistance with activities of daily living. The physicians report and hospital records confirmed that R1’s primary diagnosis as Acute Renal Failure while a hospital charting note indicated a possibility of a possible UTI but could not be confirmed.

Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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: 05/19/2023
NARRATIVE
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The Department understand having a diagnosis of chronic kidney disease give a person a higher risk for frequent UTI. Although staff cannot prevent UTIs from happening, their knowledge of R1 diagnosis and being proactive with the circumstance, staff were able to find the necessary assistance R1 needed. Thus, the allegation of resident sustained a bladder infection and a urinary tract infection (UTI) while in care of facility is deemed unsubstantiated at this time.

Regarding staff did not seek timely medical attention for resident. Interview with Executive Director (ED) Kortnie Spitznogle on 10/13/2022, starting at 1:16 p.m. and on 01/04/2023 starting at 12:25 pm, revealed that although R1 was considered independent, R1 required staff assistance with activities of daily living (ALD) from August 2022 through December 2022. ED Spitznogle added that R1 started presenting with unusual behaviors such as staying in bed, not wanting to eat, and having incontinence issues causing various incidents between August 2022 and October 2022. Additionally, ED Spitznogle stated that staff would report the incident to the ED, R1’s family members and R1’s doctor, but ultimately, it was R1’s decision to refuse care. The few times R1 went to the hospital, it was because R1’s family member convinced R1, or R1 was feeling very bad. On 10/06/2022, R1 was sent out to be evaluated and returned on 10/16/2022, with tubes in their back. ED Spitznogle added that R1 was sent out to the hospital on 10/23/2022 because R1 had pulled their tubes out of their body. R1 was admitted to the hospital, transferred to a skilled nursing facility (SNF) and was re-admitted to Pacifica Senior Living on 12/02/2022. Lastly, ED Spitznogle added that on 12/19/2022, R1 had an unwitnessed fall, initially refused medical services but was sent out to the hospital after speaking with R1 and R1’s family member. R1 did not return from recent hospitalization. Staff interviews on 10/12/2022, and 03/07/2023 confirmed what ED Spitznogle stated. Additionally, staff stated that R1 would request assistance from the care staff who would assist R1 in their needs. When staff would arrive at R1’s bedroom, there were a handful of incidents that R1 would not be feeling well and staff would call 911, but R1 would refuse to leave for additional medical attention. Additionally, staff interviews indicated they document any refusal from any resident that experiences incidents that require medical attention. Lastly, staff indicated that depending on the severity of incident, when staff recommends medical attention and resident refused, staff will contact the resident responsible party to convince to seek medical attention. Although R1 was considered independent, an apparent change in condition in R1 caused facility staff to be reactive and seek medical attention, while understanding R1’s right to refuse medical care.

Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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: 05/19/2023
NARRATIVE
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On 10/13/2022, 03/07/2023 and 05/02/2023, a file review on R1 was conducted confirming what ED Spitznogle and staff stated. Additionally, R1’s file review indicated that R1 moved into Pacifica Senior Living Oxnard on 02/12/2022, and required minimal assistance with transfers, dressing, bathing, grooming, and required no assistance with eating, toileting and managing cash resources. Further file review for R1 revealed two (2) Internal Incident Reports, 09/21/2022, and 12/09/2022, and Narrative Charting notes, 09/21/22, indicating R1’s incidents, staff seeking medical attention for R1 and R1 refusing medical care, confirming what ED Spitznogle and staff stated.

Although the staff did seek medical attention for R1 and documented those occurrences, R1 exercised his right to refuse medical care when emergency medical services arrived. The facility did its due diligence in calling emergency service when an incident happened, and, although R1 refused medical services, the facility was reactive in reaching out to R1’s family member for additional help and guidance, ultimately seeking treatment for R1. Thus, the allegation of staff did not seek timely medical attention for resident is deemed unsubstantiated at this time.

Lastly, regarding staff did not properly prepare food in result of resident getting food poisoning. Interview with Executive Director (ED) Kortnie Spitznogle on 10/13/2022, starting at 1:16 p.m. and on 01/04/2023 starting at 12:25 pm, revealed that they have not heard on any resident having any food poisoning because of the food prepared here. ED Spitznogle stated that in April 2022, there was a norovirus outbreak that was reported to Community Care Licensing (CCL) and Ventura County Public Health (VCPH). We also had some type of stomach flu a few weeks ago but that was both staff and resident. Currently, we have 2-3 resident that are exhibiting loose bowel symptoms, but those residents are on special medication that causes these types of symptoms. ED Spitznogle stated that they were in the kitchen prepping and cooking food for the community, but most recently have hired a Dinning Service Director (DSD) as their main chef.

Interview with three (3) staff on 03/07/2023, revealed that there was an incident over a year ago with the norovirus, but have not hear of any issues in recent times. Interviews with staff also revealed that residents complain of the food being served as being undercooked and not of good quality. Additionally, staff interviews indicated that 3 residents are the only resident with incontinence issues as two (2) residents take medication while the other has a medical issue. Lastly, staff interviews advised LPA to look in resident charting notes as staff record any incontinence problems any residents have.

Continued on LIC 9099 - C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
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: 05/19/2023
NARRATIVE
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Residents file review was conducted on 10/13/2022, 03/07/2023 and 05/02/2023, revealing that R2 had an incontinence episode on 08/09/2022, R3 had incontinence episode on 08/09/20233 and 08/14/2022, and R4 had and incontinence episode on 08/01/2022. LPA Ascencio did not find any other supporting documents relating to incontinence episode for other residents. On 05/02/2023 and on 05/05/2023, interview with seven (7) residents revealed that they have not experience any food poisoning or have not heard of any resident having food poisoning because of the food at the facility. Lastly, residents had mix feeling about the food being serve with some resident enjoying the food and other not liking it.

Even though there was a substantiated complaint on 10/25/2022 that addressed poor quality of food, staff and resident interviews indicated that there was a Norovirus outbreak in April 2022 that was reported but no evidence of food poisoning at this time. In addition, resident charting notes revealed only 3 residents having incontinence problems, but those incidents were attributed to medical or medication issues. Thus, based on evidence gathered this allegation is unsubstantiated at this time.

Exit interview conducted and copy of the report was issued to the Administrator.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8