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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:00:49 PM


Document Has Been Signed on 10/19/2023 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:TIERRE THORNTONFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 42DATE:
10/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Karen EncisoTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - deficiencies visit due to a deficiency observed during the course of a complaint investigation (complaint control number 29-AS-20231012084108). LPA met with acting Executive Director (ED) Karen Enciso, LVN, and explained the reason for the visit.

At 10:53 a.m. LPA reviewed and obtained pertinent records and while meeting with the ED. At 12:00 p.m. LPA observed Resident 1 (R1) in the dining room. Starting at 12:10 p.m. LPA conducted interviews with staff 1 (S1), staff 2 (S2), staff 3 (S3), and staff 4 (S4).

Resident 1 (R1) was admitted to this facility in May of 2022. R1's physician report dated 5/10/2022 indicates R1 needs full assistance from facility staff for all activities of daily living: bathing, dressing, toileting, feeding and managing cash resources. R1's family manages the cash resources. During interviews with the ED and staff, they confirmed R1 needs full assistance with all R1's care needs.

LPA observed R1 in the dining room during lunchtime. R1 was fully assisted with eating and drinking. LPA observed S4 cutting food, feeding R1 with a fork and picking up R1's glass which had a straw so R1 could take a drink. R1 did not handle any food, utensils, cups or glasses. During interviews with staff it was revealed R1 is unable to take their own medications. Medication Technicians must either put the medications on a spoon into R1's mouth or use a medication cup to pour the medications (pills/capsules) into R1's mouth, followed by holding a glass with a straw so R1 can take a drink.

Based on the records reviewed and interviews, R1 depends on others to perform all activities of daily living and appears to need a higher level of care. The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2023 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2023
Section Cited
CCR
87615

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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5)Residents who depend on others to perform all activities
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The ED will notify R1 and R1's representatives by 10/24/2023 of R1's need for a higher level of care and provide a copy of the notification to CCL by that date.
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of daily living for them as set forth in Section 87459, Functional Capabilities.
This requirement is not met as evidenced by: The facility did not comply with the section cited above as staff must perform all activities of daily living for R1, which poses an immediate health and safety risk to person 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: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023
LIC809 (FAS) - (06/04)
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