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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 08/21/2024
Date Signed: 08/21/2024 04:48:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/07/2023 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20230807101835
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: 36DATE:
08/21/2024
UNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Rick OldsTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not respond to resident's call button in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with executive director/administrator (ED) Rick Olds and explained the reason for the visit.
On 8/10/2023, LPA conducted an initial complaint investigation visit. LPA interviewed the ED at that time, Elizabeth Whittington, and obtained pertinent documents.
Regarding the allegation: Staff did not respond to resident's call button in a timely manner. LPA had obtained copies of the call button response times for 7/25/2023, which was the date in question. The following was noted:
-calls which took 16 – 30 minutes for response: seven
-calls which took over 30 minutes for response: three
-calls to resident rooms which went unanswered: two
(continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
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-20230807101835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING OXNARD
FACILITY NUMBER: 565802425
VISIT DATE: 08/21/2024
NARRATIVE
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(continued from LIC9099)

According to the ED at the time, staff are trained to respond immediately or no longer than fifteen (15) minutes. Based on the call response printout for 7/25/2023, the allegation staff did not respond to the resident’s call button in a timely manner is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.
Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230807101835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING OXNARD
FACILITY NUMBER: 565802425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee will submit a plan to conduct testing on the call buttons to ensure they are functioning properly and conduct audits on response times.
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This requirement is not met as evidenced by: Based on interviews and record review of alert response times, some responses were not completed in a timely manner and other calls went unanswered, which posed a potential health and safety risk to residents 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/07/2023 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20230807101835

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: 36DATE:
08/21/2024
UNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Rick OldsTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff refused to accept resident back from hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. LPA met with executive director/administrator (ED) Rick Olds and explained the reason for the visit. On 8/10/2023, LPA conducted an initial complaint investigation visit. LPA interviewed the ED at that time, Elizabeth Whittington, and obtained pertinent documents.

Regarding the allegation: Staff refused to accept resident back from hospital. LPA interviewed the ED at that time, Elizabeth Whittington, who stated resident 1 (R1) had been sent to the hospital due to R1 having an unusually high level of confusion. While R1 was in the hospital, R1 was given a new prescription requiring injections. When the ED learned of this new prescription, she notified R1’s responsible party that R1

(continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
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 5
Control Number 29-AS-20230807101835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING OXNARD
FACILITY NUMBER: 565802425
VISIT DATE: 08/21/2024
NARRATIVE
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(continued from LIC9099)

could not return to the facility unless R1 was able to demonstrate the ability to give themselves injections. The ED stated they did not evict R1, they just informed R1’s responsible party that R1 would need to be trained on how to do the injections prior to returning to the facility. The facility is not a medical facility, they do not have a nurse on staff 24/7 to give injections, and the caregivers are not skilled medical professionals. The ED explained to R1’s responsible party that R1 must be able to give themselves the injections in order to remain a resident of the facility.

During today's visit, the current ED indicated R1 is still living at the facility and receives the injections from a home health agency nurse on a daily basis.

Based on this information, this allegation is deemed Unsubstantiated at this time.

No deficiency cited. Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5