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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 12/13/2021
Date Signed: 12/14/2021 10:27:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:GUTIERREZ, SARAFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 50DATE:
12/13/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Kortnie Spitznogle who is authorized to review and sign reports.

During review of resident #1's facility file, LPA did not notice a Service Plan in the folder. LPA spoke with Resident Care Director (RCD) regarding missing Service Plan. RCD stated they completed an assessment for R1 and was signed by family. RCD proceeded to print a copy of the Needs and Service Plan dated and signed by family on 04/28/2021. Upon further review of resident file, LPA observed a Physician Communication sheets, dated 11/22/2021, stating "Resident was sent out to the hospital 11/22/21 @ 3:00 p.m. due to change in condition." Another Physician Communication sheet, dated 11/19/2021, stated " Resident was found on the floor for the 3rd time this week on the floor. Resident had an unwitnessed fall."
Another Physician Communication sheet, dated 11/19/2021, stated " Resident returned from hospital 11/17/21 @ 10:30 a.m. w/ fractured ankle." LPA also observed Narrative Charting notes that mentioned R1's multiple falls, fractured ankle, and change in condition. LPA questioned RCD if a new Needs and Service Plan was created due to the change in condition R1 had been presenting. RCD stated " no we have not. But, we will do that right away." LPA educated staff on when a reappraisal is needed.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Copy of the report and appeal rights given to admin via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/24/2021
Section Cited

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87463(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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Based on interviews, observation and record review, the licensee did not comply with the section cited above as there was no updated Needs and Service plan for R1 after returning from the hospital which poses a potential health, safety and personal rights violation 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021
LIC809 (FAS) - (06/04)
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