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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802425
Report Date: 10/25/2022
Date Signed: 10/25/2022 06:35:03 PM

Document Has Been Signed on 10/25/2022 06:35 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: 52DATE:
10/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Kortnie SpitznogleTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management visit at the above facility. LPA met with Executive Director (ED) Kortnie Spitznogle at 12:30 p.m.

During a facility tour on 10/13/2022, LPA observed two (2) housekeeping staff that did not wear face coverings while in the facility, as required by the CA Dept. of Public Health Guidance on the Use of Face Coverings issued June 18, 2020 and updated November 16, 2020, and an individual mask exception did not apply. LPA advised ED that all staff are required to wear a mask. Housekeepers proceeded to wear a face cover. On 10/25/2022 , starting around 12:35 p.m., LPA observed two (2) kitchen staff not wearing face. LPA met with ED and explained mask requirements are mandatory. That same day, at 12:24 p.m., LPA observed a fire exit door on the north-east stairwell, propped open with a door wedge.

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, today's report and appeal rights were reviewed and emailed to ED.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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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Document Has Been Signed on 10/25/2022 06:35 PM - It Cannot Be Edited


Created By: Angel Ascencio On 10/25/2022 at 01:11 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: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2022
Section Cited
CCR
87203

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by
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ED will contact local Fire Marshal to conduct all staff training on regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. ED will submit the training materials and attendees to CCL.
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Based on observation, the Licensee did not comply with the section cited above as LPA observed 2 fire exit door at the stairwell being propped open with a door wedge which poses an immidiate health, safety and personal rights risk to persons in care.
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Type A
10/26/2022
Section Cited
CCR87468.1

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87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the
following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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ED will conduct all staff meeting regarding CA Dept. of Public Health Guidance on the Use of Face Coverings issued June 18, 2020 and updated November 16, 2020. ED will submit the training materials and attendees to CCL.
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Based on observation the licensee did not comply with the section cited above as on 10/13/2022 and 10/25/2022,two (2) housekeepers and 2 kitchen staff were observed without a face mask upon arrival 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:Angel Ascencio
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022


LIC809 (FAS) - (06/04)
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