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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 03/01/2023
Date Signed: 03/01/2023 02:57:29 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
12/10/2021 and conducted by Evaluator Angel Ascencio
COMPLAINT CONTROL NUMBER: 29-AS-20211210101025
FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:GUTIERREZ, SARAFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 48DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Cynthia GarciaTIME COMPLETED:
03:15 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) Angel Ascencio conducted a subsequent visit to deliver the findings to the above facility. LPA met with Business Office Manager (BOM) Cynthia Garcia at 9:15 a.m. Entrance interview conducted.

On 12/10/2021, the Department (RO) received a complaint regarding staff did not respond to residents call button in a timely manner. On 03/01/2023, interviews with four (4) staff members, starting at 12:35 p.m. revealed that all residents in assisted living (AL) have a call button. When residents need assistance, they push the button alerting staff member on their pagers. Once a call button is pressed, staff head to the room as soon as possible or call for help, shut off the alert button with their own button they have, then assist the resident in need. Further interviews revealed that staff need to try to assist residents by the 4th call on their pager, which is about 15 minutes, but there have been times that they are not able due to lack of staff.

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: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 4
Control Number 29-AS-20211210101025
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: 03/01/2023
NARRATIVE
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Although staff stated they respond to the resident call buttons as soon as possible, staff believe the lack of equipment, such as pagers and walkies, contributes to the delayed response time when a resident calls for assistance.

LPA reviewed the facility's procedures and policy at it pertains to call response and it states at the bottom in handwritten black ink, “Note: 15 min response time. Do not forget to reset!! Time is crucial!!”. LPA could not find anything else regarding response time.

On 03/01/2023, starting at 12:00 p.m., LPA Ascencio reviewed the SMARTcare Alert Call Button report for Resident #1 (R1) which revealed that from 12/01/2021 - 12/13/2021 there were fifty-five (55) alert button announcements that have elapsed the company’s fifteen (15) minute policy. Additionally, further review of the SMARTcare report also revealed that there were fifteen (15) alerts that were never responded to from 12/01/2021 – 12/13/2021.

Based on the information from the investigation, there is sufficient evidence to support the claim that staff are not responding to residents’ calls for assistance in a timely manner. This allegation is substantiated.

Similar complaints were substantiated on 10/26/2021, 03/18/2022, 10/25/2022 and 02/15/2023.

1 citation was issued. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).

Exit interview conducted and a copy of the report, and appeal rights were provided to BOM.

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

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20211210101025
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: 03/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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The VP of Operations agreed to the following:
1. Review policies and procedures around responding to pendants and addressing diapering needs to all staff. Send sign-in sheet to CCL no later than 3/17/2023. Obtained additonal equiptment for staff such as walkies, and pagers.
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Based on record review and interviews, the licensee did not comply with the section cited above the staff did not respond to R1’s calls for assistance in a timely manner and R1's diapering needs were not met, which poses a potential health, safety and personal 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: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4