565802425-10-29-2021-29-AS-KHEN-C923JE-20211122171724

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 10/28/2021
Date Signed: 10/29/2021 10:32:28 AM

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
05/21/2021 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20210521114142

FACILITY NAME:	PACIFICA SENIOR LIVING OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	GUTIERREZ, SARA		FACILITY TYPE:	740
ADDRESS:	2211 E GONZALES RD		TELEPHONE:	(805) 983-6808
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	100	CENSUS: 48	DATE:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Kortnie Spitznogle		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff inappropriately restrained resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent complaint visit to close out the allegation at the facility. LPA Ascencio met with Administrator Kortnie Spitznogle at 1:37 p.m. Entrance interview conducted.

The Woodland Hills Regional Office (RO) received a complaint on 05/21/2021 alleging that staff inappropriately restrained resident while in care. During the course of the investigation, LPA Ascencio performed interviews, file review and received pertinent documents.

Interviews with staff on 08/12/2021, 10/06/2021 and 10/21/021, and revealed that the facility has removed gait belts and other devices from the premise about a year ago.

Continued on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210521114142

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: 10/28/2021

NARRATIVE

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Further interviews revealed that no resident have been restrained and it is not part of their training criteria via video training or shadow training. Additional interviews revealed that staff members have not seen, heard or participated in any type of restraining of the residents.

Review of resident files on 08/12/2021 revealed that five (5) out of forty-eight (48) resident’s Annual Assessment and Physicians Report states that they do not require restraining devices to provide care. Interviews with residents on 10/21/2021 and 10/26/2021 revealed that eight (8) out of 48 residents have not been restrained while in care.

Based on the evidence gathered, the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred , therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. Copy of the report provided to Admin via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

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