565802425-11-10-2021-29-AS-KHEN-C8VUA2-20211118142400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 11/10/2021
Date Signed: 11/10/2021 03:36:42 PM

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
06/05/2020 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20200605113632

FACILITY NAME:	PACIFICA SENIOR LIVING OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	MAHLER, KENNETH		FACILITY TYPE:	740
ADDRESS:	2211 E GONZALES RD		TELEPHONE:	(805) 983-6808
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	100	CENSUS: 48	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Kortnie Spitznogle		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Executive Director Kortnie Spitznogle at 10:20 AM. Entrance interview conducted.

The Woodland Hills North Regional Office (RO) received a complaint on 06/05/2020, alleging that a resident sustained unexplained injuries while in care. During the course of the investigation, LPA Ascencio conducted interviews with staff, residents, responsible parties, and outside agencies on 06/15/2020, 10/20/2020, 12/04/2020, 12/08/2020, 10/4/2021, and 10/21/2021. On 10/06/2021, LPA also reviewed facility files and obtained pertinent documents.

Continued on LIC - 9099 - C

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: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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-20200605113632

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: 11/10/2021

NARRATIVE

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Interview on 12/08/2020 with social worker #1 (SC) revealed that resident #1 (R1) had a skin tear in their arm around 06/05/2020. SC continued that staff present at the time did not know what happened and were not cooperative. Review of resident file chart notes on 10/06/2021 revealed that there was no recollection or written statement about a skin tear on R1’s arm. Interviews with staff revealed that R1 started hospice services on 04/28/2020 and was seen frequently by hospice services until R1 moved out of the facility in 06/08/2020. Also, R1 had multiple falls and frequent trips to the hospital between 04/28/2020 and 06/08/2020. Additional interviews revealed that R1 passed away August 2020.

Although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is unsubstantiated.

Exit interview conducted. A copy of this report provided to Executive Director via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC9099 (FAS) - (06/04)

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