565802425-10-13-2022-29-AS-JAPL-CSBVH2-20230530162615

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 10/13/2022
Date Signed: 10/13/2022 06:56:16 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:	10/13/2022
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Kortnie Spitznogle		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Staff did not keep facility free from pests.
Resident’s bathroom is in disrepair due to staff not repairing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted an unnanouced, initial complaint visit to the facility above, LPA met with Executive Director Kortnie Spitznogle at 1:16 p.m. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 10/12/2022 regarding staff did not keep facility free from pest and resident's bathroom is in disrepair due to staff not repairing. On 10/13/2022, LPA Ascencio conducted an interview with Executive Director (ED) Kortnie Spitznogle at 1:16 pm. ED Spitznogle stated they did find a mouse in the kitchen. ED added that a company came to fix teh air conditioning and left the ceiling hatch open. ED added that they placed traps in the kitchen and were able to catch the vermin in the kitchen. ED also stated they have a company EcoLabs and Teminex coming to the facility to spray the community and get rid of any other vermin if any are found. Based on interview conducted, the allegation staff did not keep teh facility free from pest is deemed Substantiated at this time.

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: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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 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: 10/13/2022

NARRATIVE

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Regarding the allegation, Resident’s bathroom is in disrepair due to staff not repairing. LPA conducted interview with ED Spitznogle at 1:16 p.m. Interview with ED revealed that Resident #1 (R1) has been having problems with their toilet. Our interim Maintenance Director has been in R1's to fix the the restroom and has changed valved but it still not working properly. ED stated at this moments R1 walked down the hall to use the public restroom. Interview with R1, starting at 04:23 p.m. revealed that the restroom has not been working for one (1) week. The staff have come to my room about two(2) - three(3) times already but have yet to fix it. R1 stated they have been walking to use the public restroom halfway down the hallway. LPA observed R1's bathroom at 04:28 p.m. and observed the water in the toilet not completely flush down. R1 stated they have yet to received an update or notice on when the toilet will get fixed. R1 has heard from other staff members that Saturday a plumber will be at the building to fix the issue. Based on observation, and staff and resident interviews, the allegation resident's bathroom is in disrepair due to staff not repairing is deemed Substantiated at this time.

2 citations were issued during today’s visit. The following deficiencies were observed (See
LIC 809-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. A copy of the report and appeal rights were provided to admin via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/14/2022 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.	1 2 3 4 5 6 7	Admin has contracted a company to remove the rodents. Admin will provide invoices of recent pest control visit to CCL by 10/14/22.
	8 9 10 11 12 13 14	Based on interviews, the Licensee did not comply with the section cited above as the ED stated they did find rodents in the kitchen which poses and immediate health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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: 10/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/21/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Admin will contract a repair company to fix R1's restroom. Admin will provide invoice of repair of R1's toilet.
	8 9 10 11 12 13 14	Based on interviews and observation, the licensee did not comply with teh section cited above as R1's toilet has not been working for 1 week which poses a potential health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC9099 (FAS) - (06/04)

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