565802425-5-3-2024-29-AS-KHEN-D5KUXL-20240524155830

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 05/03/2024
Date Signed: 05/03/2024 01:29:56 PM

Unsubstantiated

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
05/01/2023 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20230501145259

FACILITY NAME:	PACIFICA SENIOR LIVING OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	KORTNIE SPITZNOGLE		FACILITY TYPE:	740
ADDRESS:	2211 E GONZALES RD		TELEPHONE:	(805) 983-6808
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	100	CENSUS: 41	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Rick Olds		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident became severely dehydrated while in care due staff not providing adequate hydration.
Staff did not provide adequate supervision resulting in resident falling.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to issue findings regarding the above noted allegations. LPA met with facility Executive Director (ED) Rick Olds and explained the reason for the visit.

On 5/2/2023, LPA Angel Ascencio conducted the initial complaint investigation visit. LPA Ascencio met with the ED at that time, Elizabeth Whittington. LPA Ascencio toured the facility at 12:05 p.m. and reviewed and obtained pertinent documents at 12:40 p.m. LPA Ascencio informed ED Whittington further investigation was needed, and the case may be assigned to an investigator with the Community Care Licensing (CCL) Investigations Branch (IB).

(continued on page 2; 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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-20230501145259

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: 05/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from page 1; 9099)

On 5/2/2023, IB Special Investigator Assistant Eleza Jackson was assigned to the case to obtain medical records regarding Resident 1 (R1). These records were received on 7/6/2023, 7/12/2023, and 8/22/2023.

On 5/19/2023, LPA Ascencio conducted a subsequent complaint investigation visit with LPA Ashley Smith and LPA Elsie Campos. LPAs met with ED Whittington. Staff interviews were conducted between 10:00 a.m. and 1:00 p.m. LPAs informed ED Whittington further investigation was needed.

On 5/31/2023, LPA Smith and LPA Campos conducted another subsequent complaint investigation visit. LPAs met with ED Whittington and conducted a facility tour. LPAs reviewed pertinent records, interviewed staff between 10:00 a.m. and 11:15 a.m., interviewed residents between 12:00 p.m. and 1:15 p.m., and interviewed two residents’ responsible parties at 10:40 a.m. and 11:16 a.m. LPAs informed ED Whittington further investigation was needed.

On 7/13/2023, the case was assigned to IB Investigator Douglas Real for a full investigation. Investigator Real reviewed the records obtained by LPA Ascencio which showed R1 had three falls that resulted in R1 being transported to the hospital. On 2/26/2023, R1 had an unwitnessed fall in their bedroom near the bathroom. Staff found a small cut on R1’s elbow. R1 asked to go to the hospital; 9-1-1 was called and R1 was transported to the hospital. On 4/25/2023, R1 had an unwitnessed fall in their bedroom. R1 reported hitting the back of their head. Staff called 9-1-1 and R1 was transported to the hospital. R1 was released the same day with no new orders. On 4/26/2023, R1 fell from their wheelchair. R1 suffered a skin tear but was also not very responsive so 9-1-1 was called and R1 was transported to the hospital.

Investigator Real also reviewed the medical records from three separate hospitals.

R1 was seen on 4/25/2023 at a local hospital after an unwitnessed fall. Diagnostic testing was performed. No obvious signs of trauma were found and R1 was discharged back to the facility that day.

(continued on page 3; 9099-C)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230501145259

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: 05/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from page 2; 9099-C)

R1 was admitted to a different hospital on 4/26/2023 after an unwitnessed fall. Diagnostic testing was performed, and no signs of injuries were observed. R1 was discharged from this hospital on 4/28/2023.

R1 was transferred to another hospital on 4/28/2023 for further evaluation and treatment. It was found R1 was not at their baseline in terms of physical abilities so R1 was transferred to a skilled nursing rehabilitation facility on 5/1/2023.

None of the medical records identified any signs of abuse, neglect, malnourishment nor dehydration.

On 7/17/2023, Investigator Real conducted interviews with a family member and R1. On 8/17/2023, Investigator Real conducted interviews with ED Whittington at the facility. Investigator Real also conducted a telephonic interview with staff on 8/18/2023. On 9/6/2023, Investigator Real conducted interviews while at the facility with staff and other residents as well. None of the residents nor staff had ever witnessed any abuse or neglect. Residents are provided breakfast, lunch, dinner, and snacks with which beverages are provided. Additionally, there is water available throughout the day. Residents who were interviewed felt safe at the facility.

The information obtained during the Department’s investigation does not support the allegations, therefore, the allegations “Neglect/Lack of Supervision – Facility employees failed to provide an appropriate level of supervision which resulted in Resident 1 (R1) becoming dehydrated and having multiple falls in the facility” is deemed Unsubstantiated at this time.

Exit interview conducted and a copy of this report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3