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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 08:57:18 AM

Unsubstantiated


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
02/09/2024 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20240209113957
FACILITY NAME:PACIFICA SENIOR LIVING OXNARDFACILITY NUMBER:
565802425
ADMINISTRATOR:TIERRE THORNTONFACILITY 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 do not communicate effectively with a resident's licensed physician
Staff do not seek timely medical appointments for the resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit to address the allegations listed above. LPA met with Executive Director (ED) Rick Olds and explained the reason for the visit.

During today's visit LPA interviewed staff starting at 12:28 p.m. and residents starting at 1:44 p.m. LPA reviewed and obtained pertinent documents at 1:27 p.m. Based on records reviewed, when resident 1 (R1) moved into the community R1 did not require assistance with status checks or psychosocial cueing. R1's responsible party (family) was responsible for R1's medical appointments but there were issues with

(continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
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)
Page: 1 of 2
Control Number 29-AS-20240209113957
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
VISIT DATE: 09/18/2024
NARRATIVE
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(continued from LIC9099)

communicating with R1's family as they do not live in the United States. The Health and Wellness Director (HWD) observed R1's care needs had increased and when R1's family was in town they had a care plan conference in which R1's care plan was revised. The family still controls R1's medical appointments and medical needs but communicates with the HWD by email when R1 has appointments or other medical needs. The HWD arranges for transportation to appointments and a chaperone to the appointments.

Based on the information gathered, R1's family was responsible for R1's medical appointments and communicating with R1's physician, therefore these allegations are deemed Unsubstantiated at this time.

Exit interview conducted and report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2