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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 07/26/2022
Date Signed: 07/26/2022 04:55:28 PM

Document Has Been Signed on 07/26/2022 04:55 PM - It Cannot Be Edited

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:KORTNIE SPITZNOGLEFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 983-6808
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY: 100CENSUS: 48DATE:
07/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Cynthia Garcia - Business Office ManagerTIME COMPLETED:
04:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 7/22/22. LPA met with staff Cynthia Garcia - Business Office Manager.

On 7/22/22 Community Care Licensing (CCL) received an incident report from the Administrator Kortnie Spitznogle indicating that resident #1 (R1) was at a music event in the Assisted Living side and Memory Care staff was with the residents. R1 was then found by bystanders on the side of the road. Cops were called to the Community. ED/RSD ran to get R1. R1 was brought home and monitored every 2 hours that day and night. R1 was checked out by EMT. R1 was not taken to the hospital. R1's responsible person was notified. Administrator stated that staff were counciled and they have already set up retraining for 8/3/22 for all care staff.

During today’s visit LPA toured the facility with staff Garcia, review resident records and obtained copies of pertinent documents. During the facility tour at 2:24 pm with staff Garcia LPA observed 2 bottles of Weber grill cleaner in back area behind kitchen door accessible to residents. During the facility tour starting at 2:26 pm with staff Garcia LPA observed dish soap, 2 bottles of windex multisurface cleaner, and spic and span antibacterial cleaner in the activity room accessible to residents. During the facility tour starting at 2:41 pm with staff Garcia LPA observed 4 shovels in the back area of the memory care unit accessible to residents. During the facility tour starting at 2:45 pm with staff Garcia LPA observed peroxide multi surface cleaner and disinfectant, asepticare aerosol-disinfectant virucide, and a lighter in the memory care unit food service station accessible to residents. During the facility tour at 3:23 pm with staff Garcia LPA observed a paper cutter in the 1st floor copy room accessible to residents. LPA reviewed R1's records starting at 3:32 pm which revealed that R1 should be escorted by staff when leaving the community. On 7/22/22 staff failed to

Continued on 809C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 07/26/2022 04:55 PM - It Cannot Be Edited


Created By: Joann Rosales On 07/26/2022 at 04:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING OXNARD
FACILITY NUMBER: 565802425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2022
Section Cited
CCR
87464(f)(1)(c)

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Staff stated that R1 was placed on frequent checks and they have started staff retraining regarding elopement protocols. Staff stated that they will conduct a reappraisal for R1 and will provide a copy of reappraisal and staff training to CCL by 8/5/22.
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.
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Type A
07/27/2022
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff placed items in a locked office during facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(1) to CCL by 8/5/22.
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Based on LPA's observations, the licensee did not comply with the section cited above as a lighter, shovels and a paper cutter were observed accessible to residents 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


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
VISIT DATE: 07/26/2022
NARRATIVE
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supervise R1 as R1 eloped from the facility. Interview with Resident Care Director Kelly Newcomb starting at 4:31 pm revealed that S1 was found approximately 4 blocks away from the facility. R1 did not sustain any injuries.

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, todays reports were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/26/2022 04:55 PM - It Cannot Be Edited


Created By: Joann Rosales On 07/26/2022 at 04:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING OXNARD
FACILITY NUMBER: 565802425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/27/2022
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Staff placed toxic substances in a locked office during facility visit. Staff stated that they will provide documentation of staff training to CCL by 8/5/22.
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Based on LPA's observations, the licensee did not comply with the section cited above as toxic items were accessible to residents which poses an immediate health and 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


LIC809 (FAS) - (06/04)
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