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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:44:36 PM


Document Has Been Signed on 06/20/2023 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:KORTNIE SPITZNOGLEFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 47DATE:
06/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
09:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted a a Case Management – Deficieny visit to the above facility. LPA Ascencio met with Executive Director (ED) Elizabeth Whittington at 09:10 a.m.

During today’s visit, while on a facility tour at 09:31 a.m. , LPA Ascencio observed an unlocked kitchen door, in the memory care unit, that contained unknown chemicals accessible to residents in care. Staff immediately secured door to the dinning room making chemicals inaccessible. Additionally, at 09:45 a.m., LPA Ascencio observed unknown chemicals (disinfectant cleaner) in an unlocked staff lounge accessible to resident in care. At 09:46 a.m., during a tour in the staff lounge, LPA Ascencio observed two (2) knifes accessible to resident while in care. Staff secured the items in a locked location.

Two (2) citation were issued today. 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.



A copy of the report and appeal right were issued to ED Whittington.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2023 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2023
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requiement is not met as evidenced by:
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Staff placed items in a secure location while on tour with LPA. Administrator will have outside agency conduct training on section 87705 and submit documentation to CCL by 06/22/23.
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Based on observation, the licensee did not comply with the section cited above as unknown chemicals and disinfectant spray was observed in a kitchen and staff lounge accessible to residents which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Type A
06/22/2023
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia (1) (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requiement is not met as evidenced by:
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Staff placed items in a secure location while on tour with LPA. Administrator will have outside agency conduct training on section 87705 and submit documentation to CCL by 06/22/23.
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Based on LPA observation the licensee did not comply with the section cited above as kitchen knifes were in an unlocked staff lounge accessible to residents which poses an immediate health, safety or personal rights risk to persons 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: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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