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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 11/05/2024
Date Signed: 11/06/2024 08:32:48 AM

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
10/12/2023 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20231012084108
FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:TIERRE THORNTONFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 32DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Emely SalinasTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Licensee does not have sufficient staff to meet the care needs of residents
Facility staff do not ensure residents toileting needs are met in a timely manner
Facility staff do not ensure adequate supervision is provided to residents in care
Licensee does not ensure staff are properly trained to care for residents
Facility staff was asleep while at work.
Facility staff do not ensure reporting requirements are followed
Staff allowed resident to leave the facility unattended
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to issue findings on the above noted allegations. LPA met with the Business Office Manager Emely Salinas and explained the reason for the visit.

LPA previously visited the facility regarding this complaint on 9/18/2024 and 10/19/2023. During those visits LPA reviewed documents, observed resident 1 (R1), interviewed staff and residents.



(continued on LIC9099C, page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
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 4
Control Number 29-AS-20231012084108
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: 11/05/2024
NARRATIVE
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(continued from LIC9099, page 1)

Regarding the allegation: “Licensee does not have sufficient staff to meet the care needs of residents” LPA had investigated this same allegation under complaint control number 29-AS-20230918110909. On 3/8/2024, LPA had reviewed the staff schedule for caregivers and medication technicians. LPA went over concerns with the administrator Rick Olds, including no medication technicians on the schedule for Sundays and Thursdays during the NOC shift (10:00 p.m. - 6:15 a.m.). The administrator confirmed they have had some issues finding qualified staff to fill these time slots and on 3/7/2024, they did not have a medication technician during the NOC shift. Based on this information, this allegation is deemed Substantiated. Note: The same allegation was addressed and substantiated under complaint control number 29-AS-20230918110909 which covers the same time frame of this complaint.

Regarding the allegations: “Facility staff do not ensure residents toileting needs are met in a timely manner” and “Facility staff do not ensure adequate supervision is provided to residents in care” LPAs had conducted prior investigation visits to the facility on 9/18/2023, 9/25/2023, 12/12/2023, and 3/8/2024 for complaint control number 29-AS-20230918110909. Based on interviews with staff, residents were complaining to them about long wait times to receive assistance, including toileting assistance, from staff. Staff stated due to lack of staffing, residents were not being assisted in a timely manner. Interviews with residents indicated the same issue. Based on interviews, these allegations are deemed Substantiated. Note: These allegations were encompassed under complaint control number 29-AS-20230918110909 which were addressed and substantiated; this complaint covers the same time frame.

Regarding the allegation: “Staff allowed resident to leave the facility unattended”. LPA conducted interviews with staff who confirmed that resident 1 (R1) would usually wait outside in the front of the building or inside the lobby for their daughter to pick them up. On 08/21/2023, R1 was waiting in front for their daughter to take them to a dentist appointment scheduled for 3:00 p.m. The dentist is across the parking lot from the facility. Apparently, R1 decided to meet their daughter at the dentist and left the facility in their wheelchair to the dentist. R1’s daughter discovered R1 had left the facility unattended when they arrived at the facility. Although R1 had no cognitive dysfunction, R1’s physician’s report indicated R1 required assistance when leaving the facility. The facility did report this incident to CCL. Based on this information, the allegation is deemed Substantiated at this time.

(continued on LIC9099C, page 3)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20231012084108
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: 11/05/2024
NARRATIVE
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(continued from LIC9099C, page 2)

Regarding the allegation: “Facility staff do not ensure reporting requirements are followed” LPA reviewed documentation regarding reported incidents involving R1. The complaint alleged R1’s incidents were not being reported to R1’s responsible party. LPA found a facility internal incident report dated 8/3/2022 involving R1 which had no indication on the report it was reported to R1’s responsible party. Based on this information, the allegation is deemed Substantiated at this time.

Regarding the allegation: “Facility staff was asleep while at work.” LPA conducted interviews with staff. It was confirmed that at least one staff (S1) was found asleep during the NOC shift in the common area of the memory care unit. S1 was counseled and written up. Based on this information, this allegation is deemed Substantiated at this time.

Regarding the allegation: “Licensee does not ensure staff are properly trained to care for residents” LPA had investigated a similar allegation under complaint control number 29-AS-20230918110909. On 3/8/2024, LPA had reviewed the staff schedule for caregivers and medication technicians. LPA went over concerns with the administrator, including no medication technicians on the schedule for Sundays and Thursdays during the NOC shift (10:00 p.m. - 6:15 a.m.). This complaint was regarding caregivers not receiving proper training for oxygen administration. The administrator Rick Olds stated all medication technicians and some caregivers receive that training. During the time of this complaint, medication technicians were not always at the facility and it was possible some caregivers may not have had training for oxygen administration. Based on this information, this allegation 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: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20231012084108
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: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) 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 was not met as evidenced by:
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LIcensee will conduct training with staff regarding the importance of maintaining a comfortable and safe environment, including knowing which residents require assistance when leaving the facility, oxygen training and not sleeping in common areas. Evidence of training to CCL by 11/15/2024.
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Based on interviews, the licensee did not comply with the above cited section, as R1 was allowed to leave unnoticed by staff, staff was sleeping in a common area and staff require training on oxygen, which posed a potential health and safety risk to persons in care.
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Type B
11/15/2024
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency...: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
This requirement was not met as evidenced by:
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Licensee will provide a written statement of understanding regarding reporting requirements to CCL by 11/15/2024.
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Based on record review, R1's responsible party was not notified of at least one incident, which posed a potential health and safety 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4