565802425-8-2-2024-29-AS-KHEN-DACSJQ-20241024135532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:57:07 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
05/29/2024 and conducted by Evaluator Teresa Camara

COMPLAINT CONTROL NUMBER: 29-AS-20240529122225

FACILITY NAME:	PACIFICA SENIOR LIVING OXNARD		FACILITY NUMBER:	565802425
ADMINISTRATOR:	THORNTON, TIERRE		FACILITY TYPE:	740
ADDRESS:	2211 E GONZALES RD		TELEPHONE:	(805) 983-6808
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY:	100	CENSUS:	DATE:	08/02/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Rick Olds		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff are not properly trained for disaster plans.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with administrator/executive director Rick Olds and explained the reason for the visit.

On 5/31/2024, LPA had conducted an initial visit and interviewed the administrator and wellness director. During that visit the management team was not able to locate any evidence of past emergency/evacuation drills conducted with the staff. At that time, the administrator had stated the Oxnard Fire Department was going to come to the facility to conduct fire safety training with staff in mid-June 2024.

During today's visit, the administrator stated the Oxnard Fire Department told the facility they would not be able to conduct the training. The facility's life enrichment director reached out to the Ventura Fire

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: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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-20240529122225

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: 08/02/2024

NARRATIVE

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(continued from LIC9099)

Department and they have agreed to conduct training on the use of the evacuation stair chairs with facility staff in August 2024 but they have not set a date yet. In addition, staff recently received fire safety training on 7/31/2024 and a disaster preparedness meeting on 5/30/2024.

Based on interviews and lack of records for past disaster evacuation training, the allegation staff are not properly trained for disaster plans is Substantiated at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20240529122225

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/02/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/09/2024 Section Cited HSC 1569.695(c)	1 2 3 4 5 6 7	(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.	1 2 3 4 5 6 7	Administrator will provide LPA with a written statement stating he has reviewed and understand the requirements of HSC 1569.695. This will be sent to CCL on or before 8/9/2024.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section, as there were no records showing drills had been conducted, which poses a potential safety risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Perera	TELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC9099 (FAS) - (06/04)

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