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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 09/18/2024
Date Signed: 09/19/2024 08:55:03 AM

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
03/25/2024 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240325143935
FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:RICK OLDSFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 288-0159
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 35DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Rick OldsTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with Executive Director (ED) Rick Olds and explained the reason for the visit.

During today's visit, LPA conducted interviews with staff starting at 11:38 a.m. The allegation above specifically was regarding residents not receiving their medications on time and there were no medication technicians available during the NOC shift to give PRN medications to residents. LPA confirmed with staff that there was a severe staffing shortage during the time of this complaint in March of 2024. Since then the facility has hired and trained new employees in medication management. Staff confirmed there were days at the facility when medications were given late and there were no medication technicians available a couple days a week during the NOC shift. Based on this information, the above noted allegation is deemed Substantiated at this time. The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Exit interview conducted. A copy of the report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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-20240325143935
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: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Ths requirement was not met as evidenced by:
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Administrator provided LPA with a current schedule reflecting med techs on each shift. The facility has conducted hiring and medication training for new employees.
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Based on interviews and record review, the licensee did not comply with the above cited section, as there were no med techs scheduled for Sundays and Thursdays NOC shift, which poses an immediate safety risk to persons 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
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