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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 09/27/2023
Date Signed: 09/27/2023 04:56:42 PM

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
07/18/2022 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20220718090048
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: 40DATE:
09/27/2023
UNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Karen EncisoTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not receive proper training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to the facility. LPA met with acting administrator Karen Enciso, LVN, and explained the reason for the visit.

Allegation: Staff did not receive proper training
This allegation was regarding staff not being trained to assist with administering oxygen. LPA interviewed S1 who confirmed they did not receive training on oxygen administration. S1 confirmed that one night they were expected to assist a resident with their oxygen but S1 did not have training to do so and neither did any of the other staff on that PM shift. Therefore, the allegation staff did not receive proper training is deemed Substantiated at this time.

The following deficiency was 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 and a copy of the report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
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 5
Control Number 29-AS-20220718090048
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: 09/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2023
Section Cited
CCR
87618(b)(2)
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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (2) Ensuring that oxygen administration is provided by an appropriately skilled professional should the resident require assistance.
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The acting administrator agreed to submit a plan on how the facility will ensure there is oxygent administration trained staff on each shift when there are residents in the facilty on oxygen. The plan will be submitted to CCL on or before 10/4/2023.
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This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section
cited above as the facility failed to ensure staff were trained to assist resident with oxygen administration, which posed a potential health & safety risk to residents 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: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/18/2022 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20220718090048

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: 40DATE:
09/27/2023
UNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Karen EncisoTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility did not meet COVID-19 testing requirements after outbreak
Facility did not notify residents and/or responsible parties timely of COVID-19 outbreak
Staff who tested positive for COVID-19 told to report to work
Assisted Living left unattended by staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to the facility. LPA met with acting administrator Karen Enciso, LVN, and explained the reason for the visit.

Allegation: Facility did not meet COVID-19 testing requirements after outbreak
This allegation specifically referred to June of 2022 when two residents and one staff at the facility tested positive for COVID-19. LPA discussed this case with the administrator at that time, Kortnie Spitznogle. The administrator stated that she did not test other residents at the facility because the two residents who had tested positive kept to themselves. They did not dine in the dining room and they did not participate in activities. These two residents would either dine in their room or go out to eat. The staff who tested positive had not been in the facility for four days prior to testing positive. The administrator stated she discussed

(continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20220718090048
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: 09/27/2023
NARRATIVE
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(continued from 9099-A)

this with Ventura County Public Health (VCPH), and they told her mass testing was not necessary. LPA confirmed with VCPH that this information is correct. It would be reasonable to do focus testing if contact tracing found others who may have been exposed during the contagious period. In order to best utilize resources, if it is reasonable to surmise others were not exposed during the contagious period then testing was not warranted. The contagious period is considered to be 48 hours prior to testing positive or onset of symptoms. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation: Facility did not notify residents and/or responsible parties timely of COVID-19 outbreak

This allegation specifically referred to June of 2022 when two residents and one staff tested positive for COVID-19. LPA discussed this case with the administrator at the time, Kortnie Spitznogle. After the administrator discussed the cases with VCPH, it was determined this was not considered an outbreak and it was not necessary to close down the dining room or activities or do mass testing. Therefore, she did not need to notify residents/families of an outbreak since it was not considered an outbreak. Later, in July 2022, there was an outbreak in the facility and the administrator conducted testing as per VCPH guidance, shut down activities and the dining room, and contacted residents and families. Based on this information, the allegation is deemed Unsubstantiated at this time.

Staff who tested positive for COVID-19 told to report to work

This allegation was regarding a staff being told to report to work after testing positive for COVID-19. LPA attempted to contact this staff by phone three times. This staff no longer works at this facility nor is this staff currently associated with any other assisted living facility. The licensee’s human resources department provided information on this staff’s dates of work. This staff was not present in the facility for seven days after testing positive for COVID-19; staff last worked 6/12/2022, tested positive 6/16/2022 and did not return to work until 6/23/2022. At that time, Public Health recommended if staff were feeling better and not running a fever (without fever reducing medications), they could return to work after five days of testing positive. Therefore, this allegation is deemed Unsubtantiated at this time.

(continued on 9099-C)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220718090048
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: 09/27/2023
NARRATIVE
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(continued from 9099-C)

Allegation: Assisted Living left unattended by staff

This allegation was regarding two assisted living staff leaving the building to follow a resident next door to the 7-11 convenience store to prevent the resident from purchasing alcohol. LPA attempted to contact the two staff who allegedly left assisted living unattended. Neither of these two staff still work at the facility nor are they associated to any other assisted living facility. LPA tried contacting these staff by phone and by email on three separate dates, however staff did not respond. LPA spoke with another staff (S1) who stated it is possible staff left to chase after a resident who would leave the facility to go next door to the 7-11 convenience store to purchase alcohol. However, S1 also stated the walkie talkies work at 7-11. In addition, walkie talkies announce to all staff at the facility if a resident is calling for assistance. LPA was unable to confirm if assisted living residents were left unattended. Therefore, this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5