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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 04/15/2024
Date Signed: 04/15/2024 04:51:37 PM


Document Has Been Signed on 04/15/2024 04:51 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:RICK OLDSFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 288-0159
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 41DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Rick OldsTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek arrived unannounced to conduct a required annual visit. LPAs met with Executive Director Rick Olds and explained the reason for the visit.

LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

At 8:43 a.m. LPA Camara observed a medication cart in the facility lounge area that was unattended by staff. LPA checked the cart to see if it was locked, however it was not locked and there were medications stored inside the cart.

The facility's fire suppression system was last inspected by the Oxnard Fire Department on 3/11/2024. The facility's smoke detectors and carbon monoxide detectors were last inspected by Boyd & Associates on 1/12/2024, however the facility does not have documentation of this inspection. They have requested the documentation and should have it by 4/16/2024. Fire extinguishers were last serviced on 7/21/2023 and appeared fully charged.

Kitchen: At the time of the visit, the kitchen was clean and appliances appeared operable. There was a sufficient supply of perishable and nonperishable food, properly stored. The menu was posted and copies are available for residents. The facility offers daily specials and a standard selection of alternatives at every meal.

Common Areas: The facility is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors and a separate unit on the first floor is designated for memory care residents.

(continued on 809-C)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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
VISIT DATE: 04/15/2024
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(continued from LIC809)

There were no obstructions or tripping hazards observed. The facility maintains a comfortable temperature. Both facility elevators were operating properly. There are four stairwells; all are equipped with emergency evacuation chairs.

There were two delayed egress doors in the memory care unit that were not functioning properly (the main memory care entry door and one in a hallway which leads to the outdoor area accessible in assisted living). The delayed egress for these doors were tested and the doors did not open. The doors could only be opened by inputting a security code.

Activities: Planned activities are offered and the activity schedule was posted. Activity room and common spaces appeared clean and in good repair.

Rooms: LPAs toured ten randomly chosen rooms; three in memory care, one in assisted living on the first floor, three on the second floor and three on the third floor. Rooms appeared clean with sufficient lighting and appropriate furnishings.

Restrooms: Restrooms on all floors were clean and sanitary. Restrooms were fully stocked with supplies. The hot water temperature was tested on all floors and ranged from 107.0 -119.1 degrees Fahrenheit.

Outside areas: LPAs observed appropriate outdoor furniture for residents. There was an enclosed patio for residents whom reside in the memory care unit. The delayed egress doors in the memory care patio area were not operating properly and one of the doors was wired shut.

Records: LPAs reviewed five resident files and five staff files. An annual continuation visit is necessary and records will be reviewed again during that visit.

Interviews: LPAs interviewed three residents; no concerns noted.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional 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: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/15/2024 04:51 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: 04/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in four out of five delayed egress doors located in the memory care unit; the delayed egress on these doors did not operate and one door on the patio was wired shut, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2024
Plan of Correction
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The licensee will contact a repair company by 4/16/2024 to repair the delayed egress doors. Licensee will provide additional staffing in memory care until the doors are repaired. Licensee will also provide evidence of the doors being repaired.
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of one medication carts, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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Licensee will conduct refresher training with all medication technicians regarding keeping centrally stored medications inaccessible and provide evidence of this training to CCL by 4/22/2024.
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: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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