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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:53:06 PM

Unsubstantiated


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
07/23/2024 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20240723093337
FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:THORNTON, TIERREFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 34DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jovany GuerraTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff are not providing resident a copy of signed contract
Facility staff are not properly addressing insects in the facility
Facility staff are not providing privacy to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegations. The acting Executive Director Denise Downey was not at the facility. LPA met with Health and Wellness Director Jovany Guerra and explained the reason for the visit.

On 8/2/2024 and 9/18/2024, LPA interviewed staff and residents and reviewed documents. Today, 10/24/2024, LPA interviewed staff starting at 1:37 p.m.

Regarding the allegation: Facility staff are not providing resident a copy of signed contract. LPA interviewed residents who stated they received their signed admission agreement. LPA interviewed staff who witnessed Resident 1 (R1) receive a paper copy of their admission agreement on the date it was signed. In addition,

(continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 2
Control Number 29-AS-20240723093337
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: 10/24/2024
NARRATIVE
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(continued from LIC9099)

the facility provided an electronic copy of the admission agreement. Later when R1 claimed they had not received a paper copy of the admission agreement, staff printed out another copy and provided it to R1. Recently, R1 claimed again they did not receive a copy of the agreement. Staff printed another copy, however R1 refused to accept it. Based on the information obtained in interviews, this allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility staff are not properly addressing insects in the facility. LPA interviewed residents who stated they had issues in the past with ants in their apartments. These residents stated they told staff who immediately wiped up the ants and then later sent an exterminator to address it further. The facility maintenance director stated they have an exterminator come to the facility twice a month to address any issues with insects. If they need the exterminator to come to the facility between that time, the exterminator will come out right away as part of their contract. R1 stated they were experiencing issues with spiders. LPA interviewed residents near R1's room but they had not experienced any issues with spiders. LPA observed R1 had a lot of boxes in their room. The exterminator informed R1 the boxes may be the issue as spiders tend to be attracted to them. The maintenance director had called the exterminator out to address the spiders. Based on this information, this allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility staff are not providing privacy to resident.
LPA interviewed residents regarding privacy at the facility, including residents who consider themselves "independent" in that they do not require hands on care. These residents stated they usually eat meals in the dining room or participate in activities. If staff see them during the day then staff do not go into their rooms to check on them. However, if they stay in their room, for instance due to illness, then staff will knock on their door and enter their room to make sure they are ok. The administrator Rick Olds and the Health and Wellness Director both confirmed if residents who do not require care are seen in the dining room for meals and/or in activities then staff do not need to check on them. However, R1 was not going to the dining room for meals and not checking in with the receptionist so they must have staff check on R1 to make sure R1 is not in need of assistance. This has been explained to R1 by the Administrator and the Health and Wellness Director. Based on this information, this allegation is deemed Unsubstantiated at this time.

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

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
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