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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:04:57 PM

Substantiated


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
08/03/2023 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230803162328
FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:KORTNIE SPITZNOGLEFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 44DATE:
08/10/2023
UNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Elizabeth WhittingtonTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility does not have an adequate Emergency Disaster Plan.
Staff are not adequately trained in the event of an emergency.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted an intial complaint investigation visit. LPA met with executive director/administrator Elizabeth Whittington and explained the reason for the visit.

At 9:30 a.m. LPA conducted an interview with the administrator. At 10:58 a.m. LPA reviewed and obtained pertient documents.

Administrator showed LPA sign in sheets and agendas for all staff training conducted monthly. During the all staff (all shifts) training they go over emergency procedures for different emergency scenarios. These trainings are conducted monthly.

(continued on 9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
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 3
Control Number 29-AS-20230803162328
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: 08/10/2023
NARRATIVE
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(continued from 9099)

The most recent emergency procedure drill was conducted on 7/11/2023 when the facility's smoke alarm was triggered due to a resident burning something in their microwave. The administrator stated she looked at the fire panel and saw that smoke was detected so she went through with a full evacuation of the facility because at the moment she did not know what was causing the smoke. Memory care residents were evacuated to the patio area where staff made sure they stayed in the shade and stayed hydrated. All assisted living residents were evacuated to the front of the building and were kept in the shade and hydrated. Many of the residents were already downstairs but those who needed to evacuate from the second and third floor used the stairs. There was one resident on the second floor who was not able to evacuate down the stairs and staff were not confident in how to use the evacuation chair in the stairwell. The administrator stated the resident was kept at the top of the lobby stairs with a staff member. In the event of an actual emergency the fire department personnel would have immediate access to the resident so they could assist the resident in evacuating. LPA reviewed the facility's Emergency Action Plan and found it to be very comprehensive, however the facility needs to update emergency contact numbers for facility personnel and they need to post the information in the facility as well as provide an updated copy to Licensing.

Allegation: Facility does not have an adequate Emergency Disaster Plan. LPA reviewed records and found that while the facility has a comprehensive Emergency Action Plan they have not updated/posted the personnel names and their emergency phone numbers since 2018. There have been several staffing changes since then and the emergency staff contacts are outdated. Therefore, this allegation is deemed Substantiated at this time.

Allegation: Staff are not adequately trained in the event of an emergency. The administrator stated that facility staff require training on use of the evacuation chair in the stairwell. The fire department gave the administrator a number to call to set up the training with them. 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 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 via email.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230803162328
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
HSC
1569.695(b)
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§1569.695 Emergency Plans (b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.
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The administrator will contact the fire department to set up training for staff on how to use the evacuation chair. Administrator will provide the training date to CCL by 8/17/23 and a copy of the sign-in sheet once the training is completed.
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This requirement is not met as evidenced by: The facility did not comply with the section cited above as the facility staff have not been trained on how to use the evacuation chair in the stairwell which poses a potential health and safety risk to person in care.
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Type B
08/17/2023
Section Cited
HSC
1569.695(d)
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§1569.695 Emergency Plans (d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.
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The administrator will review the facility's emergency plans and make any necessary updates, including emergency staff contact information. Administrator will provide an updated LIC610E to CCL by 8/17/2023.
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This requirement is not met as evidenced by: The facility did not comply with the section cited above as the facility staff and their emergency contact numbers have not been updated which poses a potential 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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3