565802425-9-4-2024-29-AS-KHEN-D9M4LR-20240930191224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 09/04/2024
Date Signed: 09/04/2024 01:06:50 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
09/26/2023 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20230926092742

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: 37	DATE:	09/04/2024
		UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Rick Olds		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility staff are not responding to residents' calls for assistance promptly

INVESTIGATION FINDINGS:

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

On 9/27/2023, LPA Camara had conducted an initial complaint investigation visit. During that visit LPA interviewed the interim administrator and obtained pertinent documents.

(continued on LIC9099C)

Substantiated

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: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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 4

Control Number 29-AS-20230926092742

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: 09/04/2024

NARRATIVE

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(continued from LIC9099)

Regarding the allegation: Facility staff are not responding to residents’ calls for assistance promptly.

LPA reviewed the documents with the pendant call response times for 9/23/2023 (7:50 a.m. – 9:28 p.m.):

Calls that took over 15 minutes to respond: seven (7)
Calls that were announced nine times and never responded to: seven (7)

The administrator stated call response times are expected to be less than 15 minutes. Staff are trained to at least pop in to see what the resident needs and make sure it is not an emergency. At that time, if they are busy with someone else, they should let the resident know they will be back and turn off the call notification. Sometimes staff may forget to turn off the notification.

Based on the review of the pendant call response times, the allegation “Facility staff are not responding to residents’ calls for assistance promptly” is deemed Substantiated at this time. A citation was issued on complaint 29-AS-20230807101835 for the same deficiency during the same time period at the facility.

Exit interview conducted. Report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
09/26/2023 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20230926092742

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: 37	DATE:	09/04/2024
		UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Rick Olds		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Due to lack of supervision, resident left facility unassisted

INVESTIGATION FINDINGS:

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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: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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 4

Control Number 29-AS-20230926092742

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: 09/04/2024

NARRATIVE

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(continued from LIC9099A)

Regarding the allegation: Due to lack of supervision, resident left the facility unassisted.

LPA reviewed the documents obtained during the visit. Resident 1 (R1) is able to leave the facility unassisted according to R1’s physician’s report dated 1/18/2022. R1’s diagnosis did not require annual physician’s reports. R1’s assessment dated 1/18/2022 showed they could mentally and physically follow instructions in an emergency. R1 was capable of all self-care, including administering their own medication. The only assistance R1 requested was with laundry services. A re-assessment was completed on 9/27/2023 with the same level of assistance needed.

The administrator stated R1 was able to leave unassisted but R1 forgot to sign out. Facility staff were concerned because they could not find R1 and R1 did not sign out. Out of concern for R1’s wellbeing they called the police who located R1 within approximately 30 minutes and brought R1 back to the facility.

Based on documentation for R1 being able to leave without assistance, the allegation “Due to lack of supervision, resident left the facility unassisted” is deemed Unsubstantiated at this time.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

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