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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 11/19/2025
Date Signed: 11/19/2025 02:14:20 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
11/14/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20251114135432
FACILITY NAME:VISTAS AT OXNARD SENIOR LIVING,THEFACILITY NUMBER:
565802425
ADMINISTRATOR:JOVANY GUERRAFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 819-2518
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 40DATE:
11/19/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Francesca West, EDTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff did not assist resident with self-administration of medications as prescribed.
Staff did not accept resident back from hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:30 a.m., the LPA met with staff and explained the reason for the visit. At 9:34 a.m., the Executive Director (ED), Francesca West met with the LPA.

At 9:36 a.m., the LPA conducted interviews with the ED and Wellness Director (WD) Jovany Guerra. At 9:41 a.m., the LPA requested and obtained copies of pertinent documents. At 9:45 a.m., the LPA conducted a file review Resident #1 (R1’s) records. Starting at 10:10 a.m., the LPA conducted interviews with two (2) staff and two (2) residents. Between 10:13 a.m. and 10:55 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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-20251114135432
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: VISTAS AT OXNARD SENIOR LIVING,THE
FACILITY NUMBER: 565802425
VISIT DATE: 11/19/2025
NARRATIVE
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Regarding the allegation: 1.) Staff did not assist resident with self-administration of medications as prescribed. On 11/14/2025, the Department received a complaint alleging staff did not assist Resident #1 (R1) with R1’s PRN medications as prescribed. Interview with the ED and WD revealed that R1 is no longer residing at the facility. Due to R1 not residing at the facility, the LPA was not able to do a medication audit for R1, however the LPA conducted a random medication audit for four (4) residents. During today’s visit, between 10:13 a.m. and 10:55 a.m., the LPA conducted a review of medication and medication documentation with staff for four (4) residents and observed the following: Resident #2 (R2’s) Bedtime Melatonin 5MG tablet had 9 tablets remaining, however the medication was started on 11/05/2025 and with the quantity listed as 30, meaning there should be a total of 16 tablets remaining instead. R2’s Morning Atorvastatin Calcium 80MG had 15 tablets remaining, however the medication started on 11/04/2025 and with the quantity listed as 30, meaning there should be a total of 14 tablets remaining instead. R2’s Morning Lisinopril 5MG had 15 tablets remaining, however the medication started on 11/04/2025 and with the quantity listed as 30, meaning there should be a total of 14 tablets remaining instead. Resident #3’s (R3’s) Bedtime Senna 8.6MG had 11 tablets remaining, however the medication was started on 10/29/2025 and with the quantity listed as 30, meaning there should be 9 tablets remaining instead. R3’s Bedtime Trazodone HCL 100MG had 14 tablets remaining, however the medication started on 11/01/2025 and with the quantity listed as 30, meaning there should be 12 tablets remaining instead. Resident #4’s (R4’s) AM Aspirin EC 81 MG had 12 tablets remaining, however the medication was started on 11/01/2025 and with the quantity listed as 30, meaning there should be 11 tablets remaining instead. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not assist resident with self-administration of medications as prescribed” is deemed Substantiated at this time.

Regarding the allegation: 2.) Staff did not accept resident back from hospital. On 11/14/2025, the Department received a complaint alleging facility staff refusing to accept Resident #1 (R1) back to the facility from the hospital. Interview with the ED and WD revealed that R1 was admitted to the facility on 11/13/2025 and on 11/13/2025, R1 was hospitalized due to behaviors. The ED and WD explained that R1 was throwing items at staff in which staff did not feel safe for themselves and other residents. Once R1 was hospitalized, the ED wanted to reevaluate R1 to ensure that R1 was a correct fit for the facility. The ED explained that she assisted the hospital and referred them to a placement agency to assist R1 with placement. The ED said that on 11/18/2025, she followed up with the hospital and confirmed that R1 is going to be placed at a different facility that better fits their needs. Continued on LIC 9099-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20251114135432
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: VISTAS AT OXNARD SENIOR LIVING,THE
FACILITY NUMBER: 565802425
VISIT DATE: 11/19/2025
NARRATIVE
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 The LPA explained to the ED and WD that if they felt that R1 was endangering the health and safety of residents and staff or if R1 required a higher level of care, that a proper eviction notice and procedure is required. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation, “Staff did not accept resident back from hospital” is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20251114135432
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: VISTAS AT OXNARD SENIOR LIVING,THE
FACILITY NUMBER: 565802425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2025
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical&Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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The ED will schedule a medication audit for all residents and notifity the LPA when the audit is scheduled and completed. Additionally, the ED will follow up with a pharmacy to conduct an audit as well.
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Based on record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R2’s, R3’s and R4’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.
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Type B
11/25/2025
Section Cited
CCR
87468.2(a)(20)
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87468.2 (a)(20) Personal Rights of Residents ... residents in privately operated residential care facilities for ... shall have all of the following personal rights:(20) To be protected from involuntary transfers, discharges, and evictions…This requirement was not met as evidenced by:
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The WD and ED will conduct an Inservice/ education regarding the above regulation and preplacement appraisals for all staff.
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Based on record review and interviews, the Licensee did not accept Resident #1 back to facility from the hospital which poses a potential health and 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4