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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 12/17/2025
Date Signed: 12/17/2025 05:11:59 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
11/19/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20251119143627
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: 43DATE:
12/17/2025
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Francesca West, EDTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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9
Staff sleep at the facility while on shift.
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPAs), Emily Peraldi and Quoc Huynh conducted an unannounced subsequent complaint visit to this facility to deliver findings at 9:52 a.m. The LPAs met with Executive Director (ED) Francesca West and Wellness Director (WD) Jovany Guerra and explained the reason for the visit. Entrance interview conducted.

During the initial visit conducted on 11/25/2025 between 1:30 p.m. and 3:20 p.m., LPA Peraldi conducted a brief physical plant tour and interviews with the ED and three (3) staff. During today’s visit, the LPAs conducted interviews with five (5) residents and six (6) staff. Starting at 11:06 a.m., LPA Huynh along with the ED and Wellness Director (WD) conducted a physical plant tour. The LPA also obtained copies of pertinent documents during all visits.

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

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
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-20251119143627
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: 12/17/2025
NARRATIVE
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1.) Staff sleep at the facility while on shift. It was alleged that staff sleep during their shift and that management has not taken any actions towards the issue. Interviews with residents stated that they have not observed staff sleeping while on duty in addition to interviews with staff members who denied the allegation. Interview with the WD, revealed that two (2) staff members have received disciplinary actions for sleeping while on shift within the last year. Based on the information provided by interviews and record review, the above allegation is deemed Substantiated at this time and is considered a technical violation. No citations are being issued at this time, as the facility took the appropriate measures.

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: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
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
11/19/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20251119143627

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: 43DATE:
12/17/2025
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Francesca West, EDTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff members consumed alcohol during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care.
Staff locked residents in their rooms.
Staff did not meet the residents' diapering care needs in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs), Emily Peraldi and Quoc Huynh conducted an unannounced subsequent complaint visit to this facility to deliver findings at 9:52 a.m. The LPAs met with Executive Director (ED) Francesca West and Wellness Director (WD) Jovany Guerra and explained the reason for the visit. Entrance interview conducted.

During the initial visit conducted on 11/25/2025 between 1:30 p.m. and 3:20 p.m., LPA Peraldi conducted a brief physical plant tour and interviews with the ED and three (3) staff. During today’s visit, the LPAs conducted interviews with five (5) residents and six (6) staff. Starting at 11:06 a.m., LPA Huynh along with the ED and WD conducted a physical plant tour. The LPAs also obtained copies of pertinent documents during all visits.

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

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
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-20251119143627
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: 12/17/2025
NARRATIVE
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Regarding the allegations: 1.) It was alleged that staff consumed alcohol during their shift at the facility, impairing their ability to provide adequate care and supervision. Interviews conducted with staff revealed inconsistent statements regarding the allegation. Interview with the ED denied the allegations. Interviews with residents did not reveal any concerns regarding the allegation. The LPAs had conversations with the ED regarding the allegation and explained the importance of maintaining appropriate staff conduct to ensure residents health and safety. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

2.) It was alleged that staff members from the afternoon (PM) shift locked the residents in their rooms. Physical plant tours revealed that Memory Care (MC) rooms cannot be locked without the residents having the ability to unlock the door on their own. The Assisted Living (AL) rooms have individual keys for each resident and can also be unlocked from the inside. Per interview with the ED, the main entrance door locks at night from the outside, however, remains unlocked from the inside. Interviews conducted with staff denied the allegations of staff locking residents inside their rooms. Resident interviews did not reveal any concerns regarding the above allegation. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

3.) Staff did not meet the residents' diapering care needs in a timely manner. It was alleged that residents in MC were left in soiled diapers as a result of MC staff sleeping during their shift. Interviews with WD revealed that once residents press their pendants for assistance, the wait time is approximately 7-10 minutes. Residents interviewed did not express concerns regarding soiled diapers. Staff interviews revealed that wait times vary depending on current tasks, but that they try to assist residents in a timely manner to ensure residents are not in soiled diapers. Staff interviews reveal that for MC residents, they check on residents every 2 hours. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4