565802425-7-10-2023-29-AS-JAPL-CU2S5T-20230724133450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 07/10/2023
Date Signed: 07/10/2023 04:02:38 PM

Unsubstantiated

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
04/20/2022 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20220420082532

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: 44	DATE:	07/10/2023
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Elizabeth Whittington		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Resident develop pressure sores while in care.
Resident not being provided their deliveries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio arrived at the above facility to deliver findings. LPA Ascencio met with Executive Director (ED) Elizabeth Whittington at 12:10 p.m. Entrance interview conducted.

On 04/20/2022, the Department received a complaint alleging that resident developed pressure sores while in care and resident not being provided with deliveries. Interview with Administrator Kortnie Spitznogle, on 04/25/2022 starting at 10:10 a.m. revealed that Resident #1 (R1) moved into the facility on 05/20/2020. At the time of admission, R1 did not has pressure injuries, but there was a time that R1 did have pressure injuries. Over that time, we have worked very hard with the hospice agency to get R1’s pressure injury under control and it’s worked. R1 did have pressure injuries last year, but not anymore. R1 refuses to get out of the bed. R1 eats, sleeps, and gets a bed bath, all while in bed.
Continued on LIC 9099 - C Page 1

Unsubstantiated

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: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220420082532

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: 07/10/2023

NARRATIVE

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That same day, interview with R1, starting at 12:32 p.m., revealed that they are on hospice and are assisted with their needs daily by the hospice company and the caregivers at the facility. Additionally, R1 added that they do need get up from bed due to having bad legs, knees, and lower back pain. It is much more comfortable to be in bed.

Also, that same day, interview with Hospice Nurse, starting at 12:45 p.m. revealed that in December of 2021, R1 had a stage II/stage III pressure injury on their coccyx area. Additionally, R1 was admitted on 05/18/2021, on hospice services with a diagnosis of Congestive Heart Failure (CHF), Stage 3 Pressure injury and 3 other medical conditions. Hospice Nurse added that R1 does not like to get out of bed, refuses to get out of bed, thus resulting in this injury on R1’s coccyx. However, with the help of the facility caregivers, and with our hospice team, we were able to heal R1’s pressure injury. At this moment in time, there is no injury. Hospice Nurse added they do not feel the facility was at fault for R1’s pressure injuries as it was known to hospice and facility staff workers that R1 refused to get out of bed and refused care. Lastly, Hospice nurse indicated that although the facility staff stated that repositioning is a service that only a skilled nursing facility (SNF) conducted and not at an assisted living facility, R1 was repositioned every two (2) hours, per recommendation from the hospice Nurse and hospice care plan. On 06/29/2023, LPA Ascencio conducted a file review for R1 confirming what the Hospice Nurse indicated. Additionally, on 05/21/2021 through 04/04/2022, hospice notes revealed that R1 sustained either a stage 2, stage 3 or unstageable pressure wound in the coccyx area during these time periods. In addition, further review of R1’s file indicated that on 05/22/2020 an initial Home Health assessment was conducted based on MD order from a hospitalization prior to the admission at Pacifica Senior Living. Additionally, Home Health notes revealed that on 05/26/2020, facility staff informed home health of an early-stage skin breakdown at coccyx and encouraged facility staff to turn in bed every 2 hours. Home health notes from 05/27/2020 and 05/28/2020 indicates “patient refused to get out of bed. Patient with wound to coccyx” and “patient finally agreed to get out of bed…fear of falling when sitting on the edge of the bed.” Interview with Home Health Nurse on 06/29/2023, starting at 2:30 p.m. revealed that they assisted R1 various times in changing their wound at Pacifica. Home Health Nurse indicated R1 stayed mostly in their bed, and that the facility did assist R1 in bed and did their best to they could reposition them.

Continued on LIC 9099 - C Page 2

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20220420082532

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: 07/10/2023

NARRATIVE

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Although R1 did develop pressure sores while in care, home health nurse, hospice nurse and documentation revealed R1 was being assisted in all aspect of daily living, in addition to addressing the wound on R1’s coccyx and repositioning R1 every 2 hours. Interviews and documentation collaborated that the facility did not neglect R1, and that the facility was not at fault for R1 developing pressure injuries and instead showed that R1 assessed their right to refuse and stay bed. Based on evidence gathered throughout the investigation, there is insufficient evidence to support the allegation that resident developed pressure sores while in care.

Lastly regarding the allegation, resident not being provided with deliveries. Interview with R1’s Family Member on 05/04/2022 revealed that they have been shipping packages over to R1 since admission. R1 Family Member stated they send over adult briefs, wipes, utensils, plates, and telephones for R1, who indicated they do not receive the items. R1’s Family Member indicated sending emails and requested calls from the facility requesting confirmation of the packages being accepted and delivered to R1. Lastly, R1’s Family Member indicated that there have been times they did call and sent me an email confirming the packages but after I talked to Executive Director (ED) Kortnie Spitznogle, we came up with a plan keep me informed of the packages. So far, the plan is working. Interview with ED Spitznogle on 04/25/2022 revealed that all packages received at the facility are documented and then sent over to the resident’s room. With the case of R1, because they are forgetful and bed bound, when packages get delivered to R1’s room, staff place the items in a location unknown to R1, causing confusion. ED Spitznogle stated they have spoken to R1’s Family Member on various times regarding “lost” or “missing” items but they are not, they are in R1’s room, in a closet or cabinet. On 06/29/2023, LPA Ascencio received Daily Delivery Logs for January 2022, February 2022, and April 2022. Delivery logs indicated the facility receiving packages and R1 accepting those packages from staff when brough to their room. Also, LPA Ascencio received various email corresponding to R1’s Family Member from the front desk, Business Office Manager or ED regarding the acceptance of packages and confirming the deliveries of those packages to R1. Interviews with various residents on 04/25/2022, 05/03/2023 and 05/05/2023 revealed that residents have not been missing any packages. In addition, resident obtain their packages from the front desk, or they are delivered to their rooms by the staff. Lastly, interviews with residents revealed that there have never been any issues with being provided deliveries. Based on evidence gathered, there is insufficient evidence to support the claim that the resident is not being provided with deliveries.

Exit interview conducted and a copy of the report was issued. Page 3

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023

LIC9099 (FAS) - (06/04)

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