Inspection Reports for The Vistas at Oxnard Senior Living
2211 E Gonzales Rd, Oxnard, CA 93036 , CA, 93036
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related primarily to staffing shortages, delayed or missed responses to residents’ calls for assistance, inadequate supervision, and issues with medication management and resident care, including missed medications and failure to safeguard personal belongings. Several investigations substantiated problems with food service quality and timeliness, cleanliness and maintenance concerns, and personal rights violations such as locked doors restricting resident egress. The facility received multiple civil penalties totaling several thousand dollars over the years, including a recent $500 fine in September 2023 for employing staff without proper fingerprint clearance. The most recent report from August 28, 2025, found a medication error involving a missing narcotic that was promptly corrected with no immediate health or safety concerns noted. While many complaints were substantiated, several investigations found allegations unsubstantiated, and the latest inspection shows some improvement in medication handling and timely correction of issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
288% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
41% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Census: 41
Capacity: 100
Deficiencies: 0
Date: Aug 28, 2025
Visit Reason
The visit was an unannounced Case Management - Incident inspection to follow up on a self-reported incident report dated 08/08/2025 regarding a missing narcotic medication for Resident #1.
Findings
The report noted that the missing medication was replaced by the pharmacy with no delay in administration, disciplinary action was taken against Staff #1 for the medication error, and no immediate health and safety concerns were observed during the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jovany Guerra | Executive Director | Met with Licensing Program Analyst during inspection and named in relation to the medication error incident. |
| Emily Peraldi | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 100
Deficiencies: 1
Date: Aug 26, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff do not ensure the facility is kept clean and do not have access to cleaning supplies.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not ensure the facility was kept clean and did not have access to cleaning supplies. The allegation that staff did not ensure toilets were not in disrepair was unsubstantiated.
Findings
The investigation substantiated that the facility was not maintained clean and sanitary at all times, with observations of stained floors, open wires, trash, and unsanitary resident restrooms. It was noted that only one housekeeper was working and cleaning supplies access was limited. Another allegation regarding maintenance of toilets was unsubstantiated as maintenance requests were completed through outsourced vendors.
Deficiencies (1)
The facility was not clean, safe, sanitary, and in good repair at all times, including unsanitary resident toilets posing potential health and safety risks.
Report Facts
Capacity: 100
Census: 41
Deficiency count: 1
Plan of Correction Due Date: Sep 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jovany Guerra | Executive Director | Met with Licensing Program Analyst during investigation and provided information about cleaning supplies and maintenance |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager overseeing investigation |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 100
Deficiencies: 0
Date: Jul 17, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations regarding insufficient activities for residents, failure to prevent a resident from eloping, and uncomfortable temperature maintenance in the facility.
Complaint Details
The complaint included three allegations: 1) staff not providing activities for residents, 2) staff failing to prevent a resident from eloping, and 3) staff not maintaining comfortable temperatures. Each allegation was investigated through interviews, observations, and document review, and all were found unsubstantiated.
Findings
The investigation found that activities were offered daily with resident participation, the resident who eloped was found quickly and additional safety measures were implemented, and the facility maintained comfortable temperatures with resident input. All allegations were deemed unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 29-AS-20250708165142
Incident Report Date: 05/24/2025
Incident Report Submission Date: 05/27/2025
Number of residents interviewed: 4
Number of staff interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Jovany Guerra | Executive Director | Facility administrator met with Licensing Program Analyst and provided information during investigation |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 31
Capacity: 100
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The visit was conducted to verify the Chapter 7 Bankruptcy Report filed by Pacifica Senior Living as reported by the media.
Findings
The meeting confirmed multiple lawsuits against Pacifica Senior Living entities, including a $25M lawsuit in Bakersfield, a photography lawsuit, and a lawsuit against a Skilled Nursing Facility in Healdsburg. Despite these lawsuits, there was no financial impact to the properties, residents, or staff, and no vendor issues were reported. Management communicated changes to staff and residents, and the bankruptcy did not affect the communities as Pacifica Senior Living was no longer the management company.
Report Facts
Lawsuit amount: 25000000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carl Knepler | Chief Executive Officer | Provided information regarding lawsuits and financial impact |
| Stacy Barlow | Assistant Program Administrator | Conducted the meeting to verify bankruptcy report |
| Shelley Grace | Assistant Branch Chief, CCLD | Present during the meeting |
| Craig Lundgren | Legal Counsel, CCLD | Present during the meeting |
| Marlene Nelson | Director, Quality Assurance and Risk Management | Present during the meeting |
Inspection Report
Annual Inspection
Census: 31
Capacity: 100
Deficiencies: 2
Date: Mar 21, 2025
Visit Reason
The visit was a required, unannounced annual inspection conducted by Licensing Program Analysts to ensure compliance with Title 22 Regulations.
Findings
The facility was generally found to be clean, safe, and in good repair with no health and safety hazards except for two deficiencies: a non-functional west side patio door on the memory care patio and a poorly covered hole in the floor in memory care posing a tripping hazard.
Deficiencies (2)
The west side patio door on the memory care patio was not functional.
There was a poorly covered hole in the floor in memory care which posed a potential tripping hazard.
Report Facts
POC Due Date: Mar 28, 2025
Hot water temperature range: 117.1
Hot water temperature range: 118.2
Number of resident rooms toured: 10
Number of resident files reviewed: 5
Number of staff files reviewed: 5
Number of residents interviewed: 6
Number of staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jovany Guerra | Executive Director | Met with Licensing Program Analysts during inspection |
| Teresa Camara | Licensing Program Analyst | Conducted physical plant tour, medication review, interviews, and document review |
| Kelly Dulek | Licensing Program Analyst | Conducted document review during inspection |
| Desaree Perera | Licensing Program Manager | Supervisor of the inspection |
| Rick Olds | Administrator | Named in plan of correction to repair door and trip hazard |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 100
Deficiencies: 2
Date: Jan 29, 2025
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that staff did not treat residents with dignity, residents missed medications, and medications were accessible to residents in care.
Complaint Details
The complaint investigation was substantiated. Allegations included staff not treating residents with dignity, residents missing medications, and medications being accessible to residents. Interviews and record reviews confirmed these issues occurred during the reported timeframe.
Findings
The investigation substantiated all allegations: Staff member S1 spoke to residents in a disrespectful manner, residents missed medications due to improper documentation and administration, and medications were left accessible to residents, leading to medication errors. Disciplinary actions and training were implemented for S1, and a plan of correction was established.
Deficiencies (2)
Failure to keep centrally stored medicines in a safe and locked place accessible only to employees, as S1 left medications unattended on dining room tables and in an unlocked drawer.
Failure to accord residents dignity in their personal relationships with staff, as S1 spoke in a rude manner to residents.
Report Facts
Facility capacity: 100
Census: 32
Plan of Correction due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation |
| Jovany Guerra | Executive Director | Met with Licensing Program Analyst during investigation |
| Rick Olds | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 100
Deficiencies: 2
Date: Nov 5, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations including insufficient staffing, inadequate resident toileting assistance, lack of supervision, improper staff training, staff sleeping on duty, failure to follow reporting requirements, and allowing a resident to leave the facility unattended.
Complaint Details
The complaint investigation was substantiated. Allegations included insufficient staffing, untimely toileting assistance, inadequate supervision, improper staff training, staff sleeping on duty, failure to follow reporting requirements, and allowing a resident to leave unattended. The resident left the facility unattended on 08/21/2023 despite requiring assistance. Staff were found sleeping during the night shift. Incident reports were not always submitted to responsible parties. Training deficiencies were noted.
Findings
The investigation substantiated all allegations, finding insufficient staffing to meet resident care needs, delays in toileting assistance, inadequate supervision, staff sleeping during shifts, failure to notify responsible parties of incidents, and allowing a resident to leave unattended despite requiring assistance. Deficiencies were cited related to personal rights and reporting requirements.
Deficiencies (2)
Failure to provide safe, healthful, and comfortable accommodations including knowing which residents require assistance when leaving the facility, oxygen training, and staff sleeping in common areas.
Failure to submit written reports to the licensing agency and responsible parties within seven days of incidents.
Report Facts
Capacity: 100
Census: 32
Plan of Correction Due Date: Nov 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and issued findings |
| Desaree Perera | Licensing Program Manager | Oversaw the complaint investigation report |
| Rick Olds | Facility administrator who confirmed staffing and training issues | |
| Emely Salinas | Business Office Manager | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 100
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 07/23/2024 concerning issues such as failure to provide residents with signed contracts, improper addressing of insects, and lack of privacy for residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to provide residents with signed contracts, improper insect control, and lack of resident privacy. Interviews and observations supported that the facility addressed these concerns appropriately.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with residents and staff, observations, and documentation review. No deficiencies were observed during the visit.
Report Facts
Complaint Control Number: 29-AS-20240723093337
Capacity: 100
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation |
| Jovany Guerra | Health and Wellness Director | Met with Licensing Program Analyst and provided information during investigation |
| Denise Downey | Acting Executive Director | Not present at the facility during the investigation |
| Rick Olds | Administrator | Provided information regarding resident privacy during investigation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 100
Deficiencies: 1
Date: Sep 18, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not administer medication as prescribed.
Complaint Details
The complaint was substantiated based on staff interviews and record review confirming medication administration delays and lack of medication technicians during night shifts. The complaint was received on 03/25/2024 and investigated on 09/18/2024.
Findings
The investigation confirmed a severe staffing shortage during the time of the complaint in March 2024, resulting in residents not receiving medications on time and no medication technicians available during the night shift. The allegation was substantiated and a deficiency was cited related to insufficient personnel to meet resident needs.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services, specifically no medication technicians scheduled for Sundays and Thursdays night shifts, posing an immediate safety risk.
Report Facts
Capacity: 100
Census: 35
Deficiency Type: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rick Olds | Executive Director | Met with Licensing Program Analyst during investigation and involved in findings |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 100
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to address allegations that staff did not communicate effectively with a resident's licensed physician and did not seek timely medical appointments for the resident.
Complaint Details
The complaint was unsubstantiated based on information that the resident's family controlled medical appointments and communication with the physician, with the Health and Wellness Director facilitating transportation and chaperoning to appointments.
Findings
The investigation found that the resident's family was responsible for medical appointments and communication with the physician, and the allegations were deemed unsubstantiated.
Report Facts
Capacity: 100
Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rick Olds | Executive Director | Met with Licensing Program Analyst during the investigation |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 100
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that facility staff were not responding promptly to residents' calls for assistance and that a resident left the facility unassisted due to lack of supervision.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not respond promptly to residents' calls, with seven calls taking over 15 minutes to respond and seven calls never responded to. The allegation that a resident left the facility unassisted due to lack of supervision was unsubstantiated based on physician reports and assessments indicating the resident was capable of leaving unassisted.
Findings
The allegation regarding delayed staff response to residents' calls was substantiated based on pendant call response times showing multiple calls took over 15 minutes or were never responded to. The allegation that a resident left the facility unassisted due to lack of supervision was unsubstantiated, as documentation showed the resident was capable of leaving unassisted and the resident forgot to sign out.
Deficiencies (1)
Facility staff are not responding to residents' calls for assistance promptly
Report Facts
Calls taking over 15 minutes to respond: 7
Calls announced but never responded to: 7
Facility capacity: 100
Census: 37
Resident return time: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Rick Olds | Executive Director | Met with Licensing Program Analyst during investigation |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 100
Deficiencies: 1
Date: Aug 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that the administrator was not present at the facility a sufficient number of hours to adequately manage operations and that staff were not assisting residents in a timely manner.
Complaint Details
The complaint investigation was substantiated based on interviews with staff and residents indicating the administrator was not present enough to manage the facility and staff were not assisting residents timely due to staffing shortages. Prior investigations noted similar issues.
Findings
The investigation substantiated both allegations: the facility lacked a qualified administrator for several days during a severe staffing shortage, and residents experienced long wait times for assistance due to insufficient staffing. The Maintenance Director was running the facility without proper clearance and was providing care without training.
Deficiencies (1)
Failure to have a qualified and currently certified administrator on premises a sufficient number of hours to permit adequate attention to management and administration of the facility.
Report Facts
Capacity: 100
Census: 36
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Rick Olds | Executive Director/Administrator | Met with Licensing Program Analyst during investigation; facility administrator |
| Elizabeth Whittington | Executive Director | Former Executive Director who no longer worked at the facility at time of investigation |
| Kortnie Spitznogle | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 100
Deficiencies: 1
Date: Aug 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 08/07/2023 regarding staff response times to resident call buttons and refusal to accept a resident back from the hospital.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not respond timely to resident call buttons, with documented delays and unanswered calls on 7/25/2023. The allegation that staff refused to accept a resident back from the hospital was unsubstantiated after investigation.
Findings
The allegation that staff did not respond to resident call buttons in a timely manner was substantiated based on call response data showing multiple delayed and unanswered calls. The allegation that staff refused to accept a resident back from the hospital was unsubstantiated, with the facility explaining the resident needed to demonstrate ability to self-administer injections before returning.
Deficiencies (1)
Failure to ensure staff responded to resident call buttons in a timely manner, with some calls delayed or unanswered, posing a potential health and safety risk.
Report Facts
Call response delays: 7
Call response delays: 3
Calls unanswered: 2
Deficiency due date: Aug 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rick Olds | Executive Director/Administrator | Met with Licensing Program Analyst during investigation and provided information |
| Kortnie Spitznogle | Administrator | Named as facility administrator |
| Desaree Perera | Licensing Program Manager | Oversaw licensing program and signed report |
| Elizabeth Whittington | Former Executive Director interviewed during initial complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 100
Deficiencies: 1
Date: Aug 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not properly trained for disaster plans.
Complaint Details
The complaint was substantiated based on interviews and lack of records for past disaster evacuation training. The allegation that staff are not properly trained for disaster plans was confirmed.
Findings
The investigation found that there was a lack of records showing past disaster evacuation training and drills, substantiating the allegation that staff were not properly trained for disaster plans. The facility had not complied with the requirement to conduct quarterly emergency drills for each shift.
Deficiencies (1)
Failure to conduct quarterly emergency drills for each shift with documentation including date, type of emergency, and staff names, as required by HSC 1569.695(c).
Report Facts
Capacity: 100
Deficiency Plan of Correction Due Date: Aug 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Rick Olds | Administrator/Executive Director | Met with Licensing Program Analyst during investigation |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 100
Deficiencies: 5
Date: Jun 27, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2022-07-18 concerning food quality, food service adequacy, safe food handling, stock of basic food items, staff mask usage, staffing sufficiency, and response to call buttons at Pacifica Senior Living Oxnard.
Complaint Details
The complaint investigation was substantiated for allegations including poor food quality, inadequate food service, unsafe food handling, insufficient stock of basic food items, staff not wearing masks properly, insufficient staffing, and failure to respond to call buttons. Unsubstantiated allegations included limiting visitation, lack of communal activities, inadequate supervision, and unsafe environment.
Findings
The investigation substantiated several allegations including poor food quality, inadequate food service, unsafe food handling, insufficient stock of basic food items, staff not wearing masks properly during a COVID-19 outbreak, insufficient staffing leading to delayed or no response to call buttons, and late or no meal service during COVID outbreaks. Other allegations regarding visitation limits, communal activities, resident supervision, and safety environment were unsubstantiated. Multiple Type B deficiencies were cited related to food service, personal rights, staffing, and mask compliance.
Deficiencies (5)
Failure to provide food at proper temperatures, insufficient fresh produce, and running out of staple foods.
Insufficient food service personnel leading to late or no meal service during COVID outbreaks.
Staff not properly wearing face masks during outbreaks.
Insufficient staffing to meet residents' needs, resulting in late or no response to call buttons.
Insufficient personnel to provide necessary services, causing late/no meal service and delayed call button responses.
Report Facts
Census: 38
Total Capacity: 100
Call buttons unanswered: 42
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted complaint investigation and issued report |
| Desaree Perera | Licensing Program Manager | Oversaw complaint investigation |
| Rick Olds | Executive Director | Met with LPAs during investigation |
| Kortnie Spitznogle | Former Executive Director | Referenced in investigation findings |
Inspection Report
Census: 38
Capacity: 100
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
Licensing Program Analyst Teresa Camara conducted a Case Management - Other visit due to receiving notification from an outside party stating the facility is representing themselves as another name: 'The Vistas at Oxnard Senior Living'.
Findings
Upon arrival, the LPA observed that the signage and calendars inside the facility had not changed. The Executive Director stated the management company is in the process of changing the facility's name but it has not been completed. No deficiencies were observed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the Case Management - Other visit |
| Rick Olds | Executive Director | Spoke with LPA regarding facility name change |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 100
Deficiencies: 0
Date: May 3, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident became severely dehydrated due to inadequate hydration by staff and that staff failed to provide adequate supervision resulting in a resident fall.
Complaint Details
The complaint involved allegations that Resident 1 became severely dehydrated due to staff not providing adequate hydration and that staff failed to provide adequate supervision resulting in multiple falls. The investigation included multiple visits, interviews, and medical record reviews. The allegations were found to be unsubstantiated.
Findings
The investigation found no evidence to support the allegations of neglect or lack of supervision. Medical records and interviews with staff, residents, and family members did not identify any signs of abuse, neglect, malnourishment, or dehydration. The allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 100
Resident census: 41
Number of falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit and issued findings |
| Rick Olds | Executive Director | Met with Licensing Program Analyst during investigation |
| Douglas Real | Investigator | Conducted full investigation including interviews and medical record review |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 100
Deficiencies: 0
Date: May 3, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that the licensee failed to safeguard a resident's personal property, specifically that a credit card and cash were taken from a resident's room and used without permission.
Complaint Details
The complaint alleged that at least one credit card and some cash were taken from the room of resident 1 (R1) and used without R1's permission. The investigation included interviews with the resident, staff members, and a review of records. The allegation was unsubstantiated due to insufficient evidence.
Findings
The investigation found insufficient evidence to confirm that the credit card and cash were stolen from the resident's room at the facility. Therefore, the allegation that the facility failed to safeguard the resident's personal property was deemed unsubstantiated.
Report Facts
Capacity: 100
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Rick Olds | Executive Director | Met with Licensing Program Analyst during the investigation |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 41
Capacity: 100
Deficiencies: 3
Date: Apr 18, 2024
Visit Reason
The visit was an unannounced continuation of the required annual inspection to evaluate compliance with licensing regulations.
Findings
The facility is addressing delayed egress door repairs with bids pending and has increased staffing in the memory care unit. Fire alarm systems were last inspected in January 2024. The administrator is updating the Emergency Disaster Plan and will conduct quarterly evacuation drills. Medication records for one resident were incomplete but appeared to be administered as prescribed. Staff files were mostly complete, with one staff updating first aid/CPR certification. Some resident files require updates and one resident needs a new medical assessment for increased care needs.
Deficiencies (3)
One resident's centrally stored medication and destruction record (CSMDR) was incomplete.
Four residents' files needing updated and/or signed needs and services plans.
One resident will need an updated medical assessment to address a possible increase in care needs.
Report Facts
Capacity: 100
Census: 41
Number of medications reviewed: 5
Number of staff files reviewed: 5
Number of residents' files needing updates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rick Olds | Executive Director | Met with Licensing Program Analyst during inspection and involved in discussion of repair plans and documentation |
| Teresa Camara | Licensing Program Analyst | Conducted the inspection visit |
| Desaree Perera | Licensing Program Manager | Named in report signature section |
Inspection Report
Annual Inspection
Census: 41
Capacity: 100
Deficiencies: 2
Date: Apr 15, 2024
Visit Reason
Licensing Program Analysts conducted an unannounced required annual visit to ensure the facility's compliance with Title 22 Regulations and to check for health and safety hazards.
Findings
The facility was generally clean and in good repair with no obstructions or tripping hazards observed. However, two delayed egress doors in the memory care unit were not functioning properly, and a medication cart was found unattended and unlocked with medications inside.
Deficiencies (2)
Four out of five delayed egress doors in the memory care unit did not operate properly; one door on the patio was wired shut, posing an immediate health, safety, or personal rights risk.
One medication cart was found unattended and unlocked with medications inside, posing an immediate health, safety, or personal rights risk.
Report Facts
Capacity: 100
Census: 41
Deficiencies cited: 2
POC Due Date: Apr 16, 2024
POC Due Date: Apr 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rick Olds | Executive Director | Met with Licensing Program Analysts during inspection |
| Teresa Camara | Licensing Program Analyst | Conducted inspection and signed report |
| Desaree Perera | Licensing Program Manager | Supervisor and named in report |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 100
Deficiencies: 1
Date: Mar 8, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-18 alleging that the facility is understaffed.
Complaint Details
The complaint alleging understaffing was substantiated based on review of staff schedules and administrator confirmation of staffing issues during night shifts.
Findings
The investigation substantiated the allegation that the facility was understaffed, specifically noting no medication technicians were scheduled for Sundays and Thursdays during the night shift, posing an immediate safety risk.
Deficiencies (1)
No medication technicians scheduled for Sundays and Thursdays NOC shift, violating CCR 87411(a) Personnel Requirements.
Report Facts
Capacity: 100
Census: 42
Plan of Correction Due Date: Mar 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Rick Olds | Facility representative met during investigation | |
| Kortnie Spitznogle | Administrator | Facility administrator named in report |
| Desaree Perera | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 100
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 04/27/2023 regarding inadequate food service, residents being left in soiled diapers for extended periods, and residents' needs not being met at Pacifica Senior Living Oxnard.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not providing adequate food service, residents left in soiled diapers for extended times, and residents' needs not being met. The Department found no sufficient evidence to support these allegations after multiple visits, observations, interviews, and document reviews.
Findings
The investigation found insufficient evidence to substantiate the allegations. Observations and interviews with staff, residents, and family members indicated adequate food service, timely changing of residents in diapers, and that residents' needs were being met, including scheduled showers and availability of podiatrist and hairdresser services.
Report Facts
Capacity: 100
Census: 41
Complaint received date: Apr 27, 2023
Visit start time: 145
Visit end time: 195
Podiatrist visit frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Martha Arroyo | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Karen Enciso | Interim Executive Director | Met with Licensing Program Analyst during the inspection visit |
| Kortnie Spitznogle | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 100
Deficiencies: 1
Date: Oct 19, 2023
Visit Reason
The visit was a case management - deficiencies visit conducted due to a deficiency observed during the course of a complaint investigation (complaint control number 29-AS-20231012084108).
Complaint Details
The visit was triggered by a complaint investigation with complaint control number 29-AS-20231012084108.
Findings
The facility did not comply with regulations as Resident 1 (R1) requires full assistance with all activities of daily living, which the facility staff must perform. This poses an immediate health and safety risk to the resident.
Deficiencies (1)
Residents who depend on others to perform all activities of daily living shall not be admitted or retained in a residential care facility for the elderly. The facility did not comply as staff must perform all activities of daily living for Resident 1, posing an immediate health and safety risk.
Report Facts
Capacity: 100
Census: 42
Plan of Correction Due Date: Oct 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Enciso | Acting Executive Director, LVN | Met with Licensing Program Analyst during the visit and confirmed Resident 1's care needs |
| Teresa Camara | Licensing Program Analyst | Conducted the case management - deficiencies visit |
| Desaree Perera | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 100
Deficiencies: 1
Date: Sep 27, 2023
Visit Reason
This was an unannounced complaint investigation visit triggered by multiple allegations including staff not receiving proper training, failure to meet COVID-19 testing requirements after an outbreak, failure to timely notify residents or responsible parties of a COVID-19 outbreak, staff who tested positive for COVID-19 being told to report to work, and assisted living being left unattended by staff.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not receive proper training on oxygen administration. Other allegations regarding COVID-19 testing, notification, staff return to work, and assisted living left unattended were unsubstantiated.
Findings
The investigation substantiated the allegation that staff did not receive proper training to assist with oxygen administration, posing a potential health and safety risk. Other allegations related to COVID-19 testing, notification, staff return to work, and assisted living being left unattended were deemed unsubstantiated based on interviews, documentation, and public health guidance.
Deficiencies (1)
Failure to ensure staff were trained to assist residents with oxygen administration, violating CCR 87618(b)(2).
Report Facts
Capacity: 100
Census: 40
Deficiencies cited: 1
Plan of Correction due date: Oct 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Karen Enciso | Acting Administrator, LVN | Met with Licensing Program Analyst during investigation |
| Kortnie Spitznogle | Administrator | Administrator at time of COVID-19 outbreak allegations |
Inspection Report
Census: 41
Capacity: 100
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
A case management visit was conducted to address deficiencies observed during a facility tour at Pacifica Senior Living Oxnard.
Findings
The facility was found to have a deficiency where Staff #1 has been employed since 03/10/2023 without having fingerprint background clearance, posing an immediate safety risk. A civil penalty of $500 was issued.
Deficiencies (1)
Staff #1 employed since 03/10/2023 does not have fingerprint background clearance as required by California Code of Regulations, Title 22 and/or California Health and Safety Code.
Report Facts
Civil penalty amount: 500
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Richard Lee | Maintenance Director | Met with Licensing Program Analyst during the visit and interviewed |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 100
Deficiencies: 1
Date: Sep 14, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 07/18/2022 regarding improper use of personal protective equipment (PPE) during a COVID-19 outbreak and allegations of staff not administering medications as prescribed.
Complaint Details
The complaint investigation was substantiated for improper PPE use during a COVID-19 outbreak and unsubstantiated for medication administration allegations.
Findings
The allegation that staff were not properly wearing PPE during a COVID-19 outbreak was substantiated, with observations of staff wearing masks improperly. The allegation that staff were not administering medications as prescribed was unsubstantiated based on record reviews showing medication was given as ordered except when the resident was out of the facility or medication was given to a family member.
Deficiencies (1)
Personal Rights of Residents in All Facilities were not met as staff were not properly wearing face masks, posing a potential personal rights risk to residents.
Report Facts
Capacity: 100
Census: 42
Deficiency Type B: 1
Plan of Correction Due Date: Due date for correction is 09/28/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation visit |
| Joe Allen Cruz | Acting Resident Care Director (RCD), RN | Met with Licensing Program Analyst during investigation; from corporate office filling in as RCD |
| Karen Enciso | Interim Administrator/Executive Director, LVN | Interim administrator whose first day was scheduled on the inspection date but was out sick |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 100
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations that the facility does not have an adequate Emergency Disaster Plan and that staff are not adequately trained in the event of an emergency.
Complaint Details
The complaint was substantiated. Allegations included inadequate Emergency Disaster Plan and insufficient staff training on emergency procedures, specifically evacuation chair use. Both were confirmed during the investigation.
Findings
The investigation found that while the facility has a comprehensive Emergency Action Plan, the emergency contact information is outdated and not posted as required. Staff have not been trained on the use of the evacuation chair in the stairwell, posing a potential health and safety risk. Both allegations were substantiated.
Deficiencies (2)
Facility staff have not been trained on how to use the evacuation chair in the stairwell, posing a potential health and safety risk to persons in care.
Facility did not update or post emergency staff contact numbers since 2018, posing a potential health and safety risk to persons in care.
Report Facts
Capacity: 100
Census: 44
Plan of Correction Due Date: Aug 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Elizabeth Whittington | Executive Director/Administrator | Met with Licensing Program Analyst during investigation and provided information |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 100
Deficiencies: 1
Date: Jul 11, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints received on 04/20/2022 alleging that staff were not communicating timely with an authorized representative and that staff were not providing adequate care to a resident.
Complaint Details
The complaint investigation was substantiated regarding staff not communicating timely with the authorized representative. The allegation about inadequate care to the resident was unsubstantiated.
Findings
The investigation substantiated that staff, specifically the Executive Director, did not communicate promptly and appropriately with a resident's authorized representative, violating Title 22 regulations. However, the allegation that staff failed to provide adequate care to the resident was unsubstantiated due to insufficient evidence.
Deficiencies (1)
87468.1 Personal Rights of Residents in All Facilities (a)(9) - To have communications to the licensee from their representatives answered promptly and appropriately.
Report Facts
Capacity: 100
Census: 44
Citation count: 1
Plan of Correction Due Date: Jul 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Executive Director | Named in communication deficiency finding |
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation |
| Elizabeth Whittington | Executive Director | Met with Licensing Program Analyst during exit interview |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 100
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that staff neglected a resident while in care.
Complaint Details
Allegation was that staff neglected Resident #1 by failing to check on them every two hours and not providing daily bath and dressing assistance. The allegation was unsubstantiated based on interviews and evidence.
Findings
The investigation found insufficient evidence to support the claim of staff neglect. Interviews with staff, residents, and witnesses did not corroborate the allegation, and the resident was only at the facility for a short period during which staff were not briefed to check on them.
Report Facts
Capacity: 100
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Elizabeth Whittington | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 100
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that a resident developed pressure sores while in care and that the resident was not being provided their deliveries.
Complaint Details
The complaint was unsubstantiated. Allegations included a resident developing pressure sores while in care and not receiving deliveries. Interviews with the resident, hospice nurse, home health nurse, facility staff, and family members, along with documentation review, supported that the resident was assisted appropriately and deliveries were managed properly.
Findings
The investigation found insufficient evidence to substantiate the allegations. Documentation and interviews showed the resident did develop pressure sores but was assisted daily by hospice and facility staff, and the facility was not at fault. Regarding deliveries, evidence showed packages were received and delivered to the resident, and no issues with missing deliveries were found.
Report Facts
Facility capacity: 100
Resident census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Kortnie Spitznogle | Administrator | Interviewed regarding the complaint and facility practices |
| Elizabeth Whittington | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 100
Deficiencies: 0
Date: Jul 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff failed to provide adequate food service at the facility.
Complaint Details
The complaint alleged that the quality of food served was poor as it was served cold and that morning food service was not completed for a resident (R1). The investigation revealed that R1 was only at the facility for less than 12 hours and after dinner hours, and that food service procedures were followed appropriately. The allegation was unsubstantiated.
Findings
The investigation found insufficient evidence to support the allegation that the facility failed to provide adequate food service. Interviews with residents, staff, and witnesses did not corroborate claims of poor quality or insufficient food, and the allegation was deemed unsubstantiated.
Report Facts
Capacity: 100
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation visit |
| Elizabeth Whittington | Executive Director | Met with Licensing Program Analyst during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-12-10 regarding staff hitting residents, not safeguarding residents' personal belongings, yelling at residents, and mismanaging residents' medication.
Complaint Details
The complaint control number 29-AS-20211210101025 involved allegations of staff hitting residents, not safeguarding personal belongings, yelling at residents, and mismanaging medication. The allegations were all deemed unsubstantiated based on interviews and audits conducted between 2021-12-13 and 2023-06-20.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. Interviews with staff and residents, as well as a medication audit, revealed no proof of physical abuse, mishandling of personal belongings, yelling, or medication mismanagement. Some residents reported missing items but chose not to pursue formal complaints.
Report Facts
Missing cash amount: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits. |
| Elizabeth Whittington | Executive Director | Met with Licensing Program Analyst during entrance and exit interviews. |
| Sara Gutierrez | Administrator | Spoke about staff training on safeguarding personal belongings. |
Inspection Report
Census: 47
Capacity: 100
Deficiencies: 2
Date: Jun 20, 2023
Visit Reason
The visit was a Case Management - Deficiencies unannounced inspection conducted to evaluate compliance with care standards and safety regulations.
Findings
Two deficiencies were cited related to unsafe storage of chemicals and knives accessible to residents in the memory care unit and staff lounge, posing immediate health and safety risks.
Deficiencies (2)
Unknown chemicals and disinfectant spray were observed in a kitchen and staff lounge accessible to residents, posing an immediate health, safety, or personal rights risk.
Kitchen knives were found in an unlocked staff lounge accessible to residents, posing an immediate health, safety, or personal rights risk.
Report Facts
Deficiencies cited: 2
Plan of Correction Due Date: Jun 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Whittington | Executive Director | Met with Licensing Program Analyst during inspection |
| Angel Ascencio | Licensing Program Analyst | Conducted the Case Management - Deficiency visit |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 0
Date: May 31, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-04-27 regarding allegations of unclean facility conditions, staff failing to provide a comfortable environment, and failure to issue a refund.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included the facility being unclean, staff failing to provide a comfortable environment, and failure to issue a refund. Interviews, observations, and records review did not support these claims.
Findings
The investigation found insufficient evidence to substantiate any of the allegations. The facility was observed to be clean, staff interactions were appropriate, and a partial refund was issued according to the signed agreement. All allegations were deemed unsubstantiated.
Report Facts
Refund amount issued: 500
Community fee amount: 1000
Resident admission date: Mar 4, 2023
Resident move-out date: Mar 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elsie Campos | Licensing Program Analyst | Conducted the complaint investigation |
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Elizabeth Whittington | Executive Director | Met with LPAs during the investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 100
Deficiencies: 1
Date: May 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations that staff did not administer resident’s medication as needed, a resident sustained a bladder infection and UTI while in care, staff did not seek timely medical attention for a resident, and staff did not properly prepare food resulting in food poisoning.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not administer resident’s medication as needed. The allegations that a resident sustained a bladder infection and UTI, staff did not seek timely medical attention, and staff did not properly prepare food resulting in food poisoning were unsubstantiated.
Findings
The allegation that staff did not administer medication as needed was substantiated due to missing PRN blood pressure medications for two residents, posing an immediate health risk. The allegations regarding a resident sustaining a bladder infection and UTI, staff not seeking timely medical attention, and improper food preparation resulting in food poisoning were unsubstantiated based on staff interviews, file reviews, and resident statements.
Deficiencies (1)
Licensee did not comply with CCR 87465(a)(4) as two residents did not have their PRN blood pressure medication at the facility, preventing staff from assisting with self-administered medication, posing an immediate health and safety risk.
Report Facts
Capacity: 100
Census: 44
Deficiencies cited: 1
Plan of Correction Due Date: May 22, 2023
Residents with incontinence episodes: 3
Residents interviewed: 7
Staff interviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and medication audit |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Elizabeth Whittington | Executive Director | Met with Licensing Program Analyst during the investigation |
| Kortnie Spitznogle | Administrator / Executive Director | Provided interviews and information regarding resident care and allegations |
| Ashley Morgan | Licensing Program Analyst | Assisted in medication audit |
| Elsie Campos | Licensing Program Analyst | Assisted in medication audit |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 100
Deficiencies: 1
Date: May 2, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2022-10-12 regarding a resident experiencing numerous falls and injuries due to lack of supervision.
Complaint Details
The complaint was substantiated. Resident #1 had three falls on 2022-10-04 due to lack of supervision. Staff confirmed multiple falls but only one was reported. The resident was hospitalized and did not return. An immediate civil penalty of $1,000 was assessed due to repeat violation.
Findings
The investigation substantiated the allegation that the facility failed to provide adequate care and supervision, resulting in a resident sustaining multiple falls within one day. Staff interviews and record reviews confirmed multiple falls occurred, but only one was reported. An immediate civil penalty was assessed due to repeat violations.
Deficiencies (1)
Failure to provide adequate care and supervision to Resident #1, resulting in multiple falls within one day.
Report Facts
Civil penalty amount: 1000
Number of citations issued: 1
Number of falls: 3
Capacity: 100
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
| Kortnie Spitznogle | Executive Director | Interviewed regarding resident falls and supervision |
| Elizabeth Whittington | Executive Director | Met with during inspection entrance interview |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 100
Deficiencies: 1
Date: Apr 28, 2023
Visit Reason
The visit was a Case Management visit to issue a civil penalty related to a complaint alleging neglect and lack of supervision resulting in Resident #1 sustaining multiple pressure injuries and failure to seek timely medical attention.
Complaint Details
The complaint alleged that Resident #1 sustained multiple pressure injuries due to neglect and lack of supervision, and that facility staff failed to seek timely medical attention. The allegations were substantiated on March 18, 2022.
Findings
The investigation substantiated that Resident #1 sustained multiple pressure injuries due to facility staff neglect and lack of supervision, resulting in serious bodily injury and severe pain. The facility failed to provide appropriate care, supervision, and medical treatment, including addressing nutritional status and wound care needs.
Deficiencies (1)
Violation of Health and Safety Code §1569.312, Basic Services Requirements, and CCR Title 22, Section 87466 Observation of the Resident related to neglect and failure to seek medical attention for Resident #1.
Report Facts
Civil penalty amount: 9500
Weight loss: 20
Pain rating: 9
Immediate civil penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Whittington | Administrator | Met during the Case Management visit and acknowledged receipt of appeal rights. |
| Kasandra Lopez | Licensing Program Analyst | Conducted the Case Management visit and authored the report. |
| Desaree Perera | Licensing Program Manager | Named as Licensing Program Manager overseeing the report. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 100
Deficiencies: 1
Date: Apr 21, 2023
Visit Reason
The visit was conducted as a case management - deficiencies visit due to a deficiency observed during the course of a complaint investigation related to a theft incident reported by a resident's family.
Complaint Details
The visit was triggered by complaint control number 29-AS-20230418134450 regarding theft of cash and a debit card from a resident's purse on or about 03/31/2023. The complaint was substantiated by interviews and review of incident reports.
Findings
The investigation found that cash and a debit card were stolen from a resident's purse, unauthorized transactions were made, and the facility failed to report the incident to the Department as required, posing a potential health and safety risk.
Deficiencies (1)
Failure to comply with reporting requirements by not submitting a written report to the licensing agency regarding an incident of stolen valuables.
Report Facts
Capacity: 100
Census: 56
Plan of Correction Due Date: Apr 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the case management - deficiencies visit and complaint investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 100
Deficiencies: 1
Date: Apr 21, 2023
Visit Reason
The inspection was a case management - incident visit regarding an incident on 2023-04-10 where a resident (R1) left the facility unaccompanied by staff and was later found confused and lost by police.
Complaint Details
The visit was complaint-related due to an incident where resident R1 left the facility unaccompanied, was found confused and lost by police, and returned to the facility the same day. The complaint was substantiated by the finding of noncompliance.
Findings
The facility failed to ensure that resident R1, who was not allowed to leave unassisted, had staff assistance when signing out on 4/8, 4/9, and 4/10, posing an immediate health and safety risk. This noncompliance with regulations was documented as a deficiency.
Deficiencies (1)
Failure to comply with Basic Services requirement as staff were aware R1 was not to leave the facility unassisted but failed to ensure R1 had assistance when signing out on 4/8, 4/9, and 4/10, posing an immediate health and safety risk.
Report Facts
Census: 56
Total Capacity: 100
Deficiency Count: 1
Plan of Correction Due Date: Apr 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted the case management - incident visit and authored the report |
| Elizabeth Whittington | Administrator/Executive Director | Met with Licensing Program Analyst during the inspection |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 100
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
The visit was conducted as a complaint investigation regarding an allegation that a resident's room had mold.
Complaint Details
The complaint alleged mold in a resident's room. Multiple inspections and interviews were conducted, including with the Executive Director and the resident. Although stains and possible water damage were observed, no mold was confirmed. The complaint was unsubstantiated.
Findings
The investigation found visible water stains on the resident's apartment wall that had been painted over, but there was insufficient evidence to confirm the presence of mold. The allegation was deemed unsubstantiated.
Report Facts
Capacity: 100
Census: 48
Number of residents’ rooms inspected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and inspections |
| Kortnie Spitznogle | Executive Director | Interviewed regarding the mold complaint and facility conditions |
| Jade Alma | Interim Executive Director | Met with Licensing Program Analyst during inspection and discussed findings |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 100
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following allegations that a resident's oral hygiene needs were not met and that the resident did not receive medical care in a timely manner.
Complaint Details
The complaint alleged that a resident's oral hygiene needs were not met and that the resident did not receive medical care in a timely manner. The investigation concluded both allegations were unsubstantiated based on medical records, staff interviews, and hospice documentation.
Findings
The investigation found insufficient evidence to substantiate the allegations. Documentation and interviews confirmed that the resident was on hospice care with aggressive behaviors that limited care provision. Staff and hospice records showed attempts to provide oral care, and the resident was frequently seen by hospice staff. Both allegations were deemed unsubstantiated.
Report Facts
Facility capacity: 100
Resident census: 49
Complaint received date: Jan 13, 2022
Resident hospice admission date: Oct 11, 2021
Resident death date: Jan 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during the investigation |
| Kortnie Spitznogle | Executive Director | Interviewed regarding resident care and behaviors |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 100
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 12/10/2021 alleging that staff did not respond to residents' call buttons in a timely manner.
Complaint Details
The complaint alleged that staff did not respond to residents' call buttons in a timely manner. The allegation was substantiated based on interviews, record reviews, and SMARTcare Alert Call Button reports showing 55 alerts exceeding the 15-minute response time and 15 alerts never responded to between 12/01/2021 and 12/13/2021. Similar complaints were substantiated on 10/26/2021, 03/18/2022, 10/25/2022, and 02/15/2023.
Findings
The investigation found sufficient evidence that staff did not respond to residents' calls for assistance in a timely manner, with multiple alerts exceeding the facility's 15-minute response policy and some alerts never responded to. The allegation was substantiated and a citation was issued.
Deficiencies (1)
Staff did not respond to Resident #1's calls for assistance in a timely manner and Resident #1's diapering needs were not met, posing a potential health, safety, and personal risk.
Report Facts
Alert button announcements exceeding 15-minute response time: 55
Alerts never responded to: 15
Citation count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during entrance and exit interviews |
| Sara Gutierrez | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 100
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-12-27 regarding inadequate food service and medication administration issues at the facility.
Complaint Details
The complaint was substantiated for inadequate food service, with multiple resident interviews confirming late meals, missing items, and poor quality. The medication administration complaint was unsubstantiated based on interviews and medical record reviews.
Findings
The investigation substantiated that staff did not provide adequate food service to residents, with reports of late, cold meals, missing utensils, and poor food quality. The medication-related allegations were unsubstantiated, as records and interviews showed residents received timely medication and assistance with self-administration as prescribed.
Deficiencies (1)
Failure to provide adequate food service to residents, posing potential health, safety, and personal rights risks.
Report Facts
Capacity: 100
Census: 48
Citation count: 1
Plan of Correction Due Date: Mar 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during inspection and involved in plan of correction |
| Sara Gutierrez | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 1
Date: Feb 22, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-01-23 regarding staff not ensuring residents received meals in a timely manner, failure to inform authorized representatives of resident injury, failure to notify authorized representatives of a communicable disease outbreak, and failure to write an incident report of injury.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not ensure residents received meals in a timely manner. The other allegations regarding failure to inform authorized representatives of injury, failure to notify authorized representatives of a communicable disease outbreak, and failure to write an incident report were unsubstantiated.
Findings
The allegation that staff did not ensure residents received meals in a timely manner was substantiated based on interviews and observations. Allegations that staff failed to inform authorized representatives of a resident's injury, failed to notify authorized representatives of a communicable disease outbreak, and failed to write an incident report of injury were unsubstantiated due to insufficient evidence.
Deficiencies (1)
Staff did not provide meals to residents in a timely manner as determined by the posted meal times, posing a potential personal rights risk to residents in care.
Report Facts
Capacity: 100
Census: 47
Plan of Correction Due Date: Feb 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Executive Director | Met with during inspection and involved in findings delivery |
| Cynthia Garcia | Business Office Manager | Findings were delivered to this employee |
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 1
Date: Feb 22, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 04/25/2022 regarding inadequate food service at the facility.
Complaint Details
The complaint was substantiated. The complaint control number is 29-AS-20220425095729. The complaint alleged inadequate food service, which was confirmed through multiple resident and staff interviews and observations during the investigation.
Findings
Interviews with residents and staff, as well as observations, confirmed that food delivery times and temperatures varied daily, with meals often arriving late and cold. The food quality was reported as not the best, and staff sometimes forgot utensils and condiments. The investigation substantiated that the facility's food service is inadequate, posing potential health, safety, and personal rights risks to residents.
Deficiencies (1)
Failure to provide care, supervision, and services that meet individual needs delivered by sufficient, qualified, and competent staff, resulting in inadequate food service.
Report Facts
Capacity: 100
Census: 47
Deficiency count: 1
Plan of Correction Due Date: Feb 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Kortnie Spitznogle | Executive Director | Facility administrator met during entrance interview |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 2
Date: Feb 22, 2023
Visit Reason
The inspection visit was an unannounced Case Management-Deficiencies inspection conducted due to deficiencies observed during the investigation of complaint control #29-AS-20230123143000.
Complaint Details
The visit was triggered by complaint control #29-AS-20230123143000. The personal rights violation related to locked courtyard doors was discussed with the Executive Director on 1/23/2023 and 2/15/2023. Both deficiencies were repeat violations with civil penalties assessed.
Findings
The inspection found personal rights violations including locked courtyard doors in the dementia unit preventing egress, and accessible alcohol and cleaning supplies posing health and safety risks. Civil penalties of $250 each were assessed for repeat violations.
Deficiencies (2)
Doors to the courtyard in the dementia unit were locked from the inside, prohibiting residents from leaving the courtyard and violating personal rights.
Alcohol and cleaning supplies were accessible to residents, posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 250
Civil penalty amount: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and signed the report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor and Licensing Program Manager named in the report |
| Cynthia Garcia | Business Office Manager | Facility staff met with during the inspection |
| Kortnie Spitznogle | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 2
Date: Feb 15, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations that staff do not respond to residents' calls for assistance and that residents' diapering needs are not met in a timely manner.
Complaint Details
The complaint was substantiated. Allegations included staff not responding to residents' calls for assistance and residents' diapering needs not being met timely. Evidence included resident interviews, call button reports showing delayed or no responses, and hospice records documenting resident incontinence issues.
Findings
The investigation substantiated that staff did not respond to residents' calls for assistance in a timely manner, with evidence including call button reports and resident interviews. Additionally, residents' diapering needs were found not to be met in a timely manner, posing potential health and safety risks.
Deficiencies (2)
Staff did not respond to Resident #1's calls for assistance in a timely manner.
Resident's diapering needs were not met in a timely manner, posing potential health, safety, and personal risk.
Report Facts
Alert button announcements elapsed company policy time: 17
Alerts never responded to: 5
Instances R1 pressed pendant in April 2022: 4
Alerts failed to receive response: 1
Plan of Correction due date: Feb 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Kortnie Spitznogle | Executive Director | Interviewed during the investigation regarding resident care and pendant issues. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Annual Inspection
Census: 47
Capacity: 100
Deficiencies: 1
Date: Feb 15, 2023
Visit Reason
The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure the facility meets health and safety standards.
Findings
The facility was generally found to be in compliance with regulations, including adequate infection control, clean and well-maintained rooms, and proper food storage. However, a personal rights violation was identified due to locked exterior doors to the memory care unit courtyard, restricting resident egress.
Deficiencies (1)
Exterior doors to the courtyard in the memory care unit were locked from the inside, inhibiting residents from re-entering the facility, posing an immediate personal rights risk.
Report Facts
Capacity: 100
Census: 47
Water temperature range: 113.2
Water temperature range: 118.8
Fire extinguisher last serviced: 7
Fire extinguisher last serviced year: 2022
Smoke detector inspection date: Jun 5, 2022
Plan of Correction Due Date: Feb 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kortnie Spitznogle | Executive Director | Met with Licensing Program Analyst during inspection and agreed to plan of correction |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Census: 52
Capacity: 100
Deficiencies: 0
Date: Feb 10, 2023
Visit Reason
The visit was a Case Management visit aimed at discussing the facility's infection control practices and procedures, conducted in conjunction with local and state health departments.
Findings
No immediate health and safety concerns were noted during the visit. Recommendations were provided regarding disinfection practices, hand sanitizer availability, and staff training. No deficiencies were cited at this time.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Executive Director | Met with during the visit and explained the reason for the visit. |
| Tahania Gomez | Resident Services Director | Met with during the visit and explained the reason for the visit. |
| Ashley Smith | Licensing Program Analyst | Conducted the Case-Management visit. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 100
Deficiencies: 0
Date: Jan 31, 2023
Visit Reason
The inspection was conducted as a complaint investigation following allegations that residents were injured while in care and sustained multiple unwitnessed falls due to neglect or lack of supervision.
Complaint Details
The complaint alleged neglect and lack of supervision resulting in injuries to Resident #1 and Resident #2 from unwitnessed falls. After interviews, record reviews, and investigations, the allegations were deemed unsubstantiated due to insufficient evidence of staff negligence.
Findings
The investigation found insufficient evidence to substantiate the allegations of neglect or lack of supervision. Although residents sustained injuries from unwitnessed falls, the facility staff responded appropriately and there was no evidence of negligence.
Report Facts
Capacity: 100
Census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation report |
| Kortnie Spitznogle | Executive Director | Met with Licensing Program Analyst during the investigation |
| Laura Garcia | Investigator | Conducted multiple interviews and reviewed medical and facility records during the investigation |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 100
Deficiencies: 1
Date: Jan 23, 2023
Visit Reason
Unannounced complaint investigation visit conducted due to an allegation that the licensee is not keeping the facility free of rodents.
Complaint Details
The complaint was substantiated. The facility was cited previously on 10/13/2022 for the same issue and a civil penalty of $250 was assessed. The Executive Director acknowledged the chronic rat problem and agreed to submit a plan of correction by 01/24/2023.
Findings
Rat droppings were observed on the floor, countertops, and kitchen equipment in the kitchen area. The Executive Director admitted the facility has a chronic rat problem despite monthly pest control services. The allegation was substantiated and a civil penalty was assessed.
Deficiencies (1)
87555(b)(27) General Food Service Requirements. All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. Rodent droppings were observed in the kitchen and staff admitted to a rodent issue posing immediate health and safety risk.
Report Facts
Capacity: 100
Census: 51
Civil penalty: 250
Plan of Correction Due Date: Jan 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw complaint investigation |
| Kortnie Spitznogle | Executive Director | Facility representative who admitted rodent problem and agreed to plan of correction |
Inspection Report
Census: 51
Capacity: 100
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
The visit was an unannounced Case Management - Other visit to ensure that an excluded individual is not employed at the facility.
Findings
The facility confirmed that the excluded individual (Staff #1) had submitted an application but was not actively working or hired at the facility. Documentation was received confirming the individual could not be employed at the facility, and staff roster verification confirmed this.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Executive Director | Met with Licensing Program Analysts during the visit and confirmed receipt of documentation regarding excluded staff. |
| Ashley Smith | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Angel Ascencio | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 100
Deficiencies: 4
Date: Jan 23, 2023
Visit Reason
The inspection visit was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20230119090203.
Complaint Details
The visit was triggered by deficiencies observed during the investigation of complaint control #29-AS-20230119090203.
Findings
Multiple deficiencies were observed including standing water in fountains posing health risks, locked courtyard doors restricting egress violating personal rights, missing window screens, accessible knives in staff areas, and accessible gardening supplies posing safety risks. A civil penalty of $500 was assessed for the zero-tolerance violation related to standing water.
Deficiencies (4)
Standing water in fountains in the courtyard and in front of the building posing immediate health and safety risk.
Accessible knife in the staff break room and accessible gardening supplies and tools in the courtyard posing immediate health and safety risk.
Exterior doors to the courtyard in the memory care unit locked from the inside, violating residents' personal rights to leave or depart the facility at any time.
Missing window screen in the theater room posing immediate health and safety risk.
Report Facts
Civil penalty amount: 500
Deficiency count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Smith | Licensing Program Analyst | Conducted the inspection and named in the report. |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Supervisor named in the report. |
| Kortnie Spitznogle | Administrator | Facility administrator met during the inspection. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 100
Deficiencies: 1
Date: Jan 6, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that staff were not meeting residents' dietary restrictions and that residents were being locked inside the facility.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not meeting residents' dietary restrictions, based on interviews and observations. The allegation that residents were being locked inside the facility was unsubstantiated.
Findings
The complaint regarding dietary restrictions was substantiated, with findings that modified diets prescribed by physicians were not consistently followed, posing potential health risks. The complaint about residents being locked inside the facility was unsubstantiated, with evidence showing residents had freedom to leave, though some experienced delays in door access after hours.
Deficiencies (1)
Modified diets prescribed by a resident's physician as a medical necessity were not provided, posing a potential health, safety, and personal rights risk to residents.
Report Facts
Capacity: 100
Census: 50
Staff interviews: 6
Resident interviews: 8
Plan of Correction due date: Jan 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Kortnie Spitznogle | Administrator | Facility administrator mentioned in relation to findings and interviews |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during visits and exit interviews |
Inspection Report
Census: 50
Capacity: 100
Deficiencies: 2
Date: Jan 6, 2023
Visit Reason
The visit was an unannounced Case Management - Other inspection related to ongoing concerns about a COVID-19 outbreak at the facility, including review of compliance with communal dining and group activity restrictions and reporting requirements.
Findings
The investigation found that the facility prohibited residents not on isolation or quarantine from participating in communal dining and group activities, which is against current guidance. Additionally, the facility failed to timely report the COVID-19 outbreak to the appropriate agencies. These are repeat violations and a civil penalty of $250 was assessed.
Deficiencies (2)
Facility did not allow residents not on isolation or quarantine to participate in communal dining or activities, violating residents' personal rights.
Facility failed to report the COVID-19 outbreak to licensing agency and local health officer within 24 hours.
Report Facts
Civil penalty amount: 250
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kristin Heffernan | Licensing Program Manager | Supervisor of the inspection |
| Kortnie Spitznogle | Administrator | Facility Administrator mentioned in relation to communication failures |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during inspection |
Inspection Report
Census: 52
Capacity: 100
Deficiencies: 2
Date: Oct 25, 2022
Visit Reason
The visit was a Case Management visit conducted to assess deficiencies related to compliance with health and safety regulations, including mask-wearing and fire safety.
Findings
The inspection found that staff were observed not wearing face coverings as required by California Department of Public Health guidance, and a fire exit door was propped open with a door wedge, posing immediate health and safety risks.
Deficiencies (2)
Two fire exit doors at the stairwell were propped open with a door wedge, posing an immediate health, safety, and personal rights risk to persons in care.
Two housekeepers and two kitchen staff were observed without face masks upon arrival, posing an immediate health and safety risk to persons in care.
Report Facts
Capacity: 100
Census: 52
Deficiency count: 2
Plan of Correction Due Date: Oct 26, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Executive Director | Met with Licensing Program Analyst during the visit and discussed mask requirements |
| Angel Ascencio | Licensing Program Analyst | Conducted the Case Management visit and documented findings |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 100
Deficiencies: 2
Date: Oct 25, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following complaints received on 10/12/2022 regarding staff not responding to residents' calls for assistance and staff not providing residents with food of good quality.
Complaint Details
The complaint investigation was substantiated. The complaint involved allegations that staff did not respond to residents' calls for assistance and that residents were not provided food of good quality. The investigation confirmed these allegations based on interviews, record reviews, and observations.
Findings
The investigation substantiated that staff did not respond timely to residents' calls for assistance, with multiple alerts going unanswered or delayed. Additionally, the food quality and quantity served to residents was found to be poor, inconsistent, and not meeting dietary needs, with multiple residents and staff confirming these issues. Two citations were issued related to personal rights violations and general food service requirements.
Deficiencies (2)
Staff did not respond to resident's calls for assistance, posing potential health, safety, and personal risk.
Facility failed to provide food of adequate quality and quantity to meet residents' needs, posing potential health, safety, and personal rights risk.
Report Facts
Alert button announcements elapsed 15-minute policy: 50
Alerts never responded: 11
Residents interviewed: 7
Citations issued: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report. |
| Kortnie Spitznogle | Executive Director | Met with Licensing Program Analyst during the investigation and was the facility administrator. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Staff #1 | Dining Service Director | Head cook since August 2022, promoted from Activities Director; lacked formal dining services training. |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 100
Deficiencies: 2
Date: Oct 13, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 10/12/2022 regarding staff not keeping the facility free from pests and a resident's bathroom being in disrepair due to staff not repairing it.
Complaint Details
The complaint was substantiated. Staff did not keep the facility free from pests as a mouse was found in the kitchen and traps were set. The resident's bathroom toilet was not working for one week despite maintenance efforts, causing the resident to use a public restroom.
Findings
The investigation substantiated both allegations: rodents were found in the kitchen posing a health risk, and a resident's bathroom toilet had not been functioning properly for one week despite maintenance attempts. Two citations were issued related to these deficiencies.
Deficiencies (2)
All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
Report Facts
Deficiencies cited: 2
Capacity: 100
Census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation visit and interviews. |
| Kortnie Spitznogle | Executive Director | Interviewed regarding the allegations and findings. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 100
Deficiencies: 1
Date: Sep 23, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a scabies outbreak, resident falls resulting in injuries, failure to bathe a resident, illegal eviction, and medication administration issues.
Complaint Details
The complaint investigation was substantiated for the allegation that the facility had a scabies outbreak involving four residents, with failure to report the outbreak to the Community Care Licensing (CCL) and Ventura County Public Health. Other allegations including multiple falls resulting in injuries, failure to bathe a resident, illegal eviction, and medication administration errors were unsubstantiated due to insufficient evidence.
Findings
The allegation of a scabies outbreak was substantiated with four residents diagnosed and a failure to report the outbreak to authorities. Other allegations regarding resident falls, bathing, eviction, and medication administration were unsubstantiated due to insufficient evidence. A deficiency was cited for failure to report the scabies case as required by regulation.
Deficiencies (1)
Failure to report a scabies outbreak to the licensing agency within 24 hours as required by CCR 87211(a)(2).
Report Facts
Residents diagnosed with scabies: 4
Resident falls: 6
Facility capacity: 100
Facility census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and interviews. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Kortnie Spitznogle | Executive Director | Facility Executive Director met during the investigation. |
| Kenneth Mahler | Administrator | Facility Administrator mentioned in the report. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 100
Deficiencies: 2
Date: Aug 31, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/07/2022 regarding insufficient staffing and unmet resident incontinence needs.
Complaint Details
The complaint investigation was substantiated for insufficient staffing and unmet incontinence needs for Resident #1. The allegation that staff did not provide residents with clean linens was unsubstantiated.
Findings
The investigation substantiated two allegations: the facility had insufficient staffing causing delays in resident care, and the facility failed to meet Resident #1's incontinence needs, resulting in the resident being found saturated in urine and stool. A third allegation regarding unclean linens was unsubstantiated.
Deficiencies (2)
Facility failed to ensure adequate staffing to meet resident needs, posing an immediate health and safety risk.
Facility failed to ensure Resident #1's incontinence needs were met, leading to the resident being found not clean and dry.
Report Facts
Capacity: 100
Census: 49
Resident interviews: 6
Staff interviews: 6
Plan of Correction Due Date: Sep 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Administrator | Interviewed regarding staffing and incontinence allegations |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 100
Deficiencies: 3
Date: Jul 26, 2022
Visit Reason
The visit was conducted as a Case Management investigation of an incident that occurred on 2022-07-22, where resident #1 (R1) was found outside the facility unescorted, posing a safety risk.
Complaint Details
The visit was complaint-related, investigating an incident where resident #1 eloped from the facility unescorted. The complaint was substantiated as staff failed to supervise the resident properly.
Findings
The investigation found that staff failed to supervise R1 as required, allowing R1 to leave the facility unassisted. Additionally, several hazardous items such as a lighter, shovels, paper cutter, and toxic cleaning supplies were accessible to residents, posing immediate health and safety risks.
Deficiencies (3)
Failure to provide care and supervision as R1 left the facility unassisted, posing an immediate health and safety risk.
Lighter, shovels, and a paper cutter were accessible to residents with dementia, posing an immediate safety risk.
Toxic substances such as cleaning supplies were accessible to residents with dementia, posing an immediate health and safety risk.
Report Facts
Distance resident found from facility: 4
Plan of Correction Due Date: Jul 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Administrator | Reported the incident involving resident #1. |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during the visit and assisted with facility tour. |
| Kelly Newcomb | Resident Care Director | Interviewed regarding the incident and supervision failure. |
| Joann Rosales | Licensing Program Analyst | Conducted the case management visit and investigation. |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 100
Deficiencies: 1
Date: Jul 13, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not meet reporting requirements related to Resident #1's death notification.
Complaint Details
The complaint alleged that the facility did not report Resident #1’s death to the responsible party. The allegation was substantiated based on interviews and record review showing the facility did not notify the responsible person within seven days, although the Hospice agency had done so. The Administrator was on personal time off during the death and assumed staff had made the notification.
Findings
The investigation substantiated that the facility failed to notify the person responsible for Resident #1's death within seven days as required by regulation. The Administrator acknowledged a miscommunication and agreed to ensure future compliance with reporting requirements.
Deficiencies (1)
Failure to submit a written report to the licensing agency within seven days of Resident #1's death and failure to notify the person responsible for Resident #1's death, posing a potential health and safety risk.
Report Facts
Deficiencies cited: 1
Capacity: 100
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Administrator | Named in relation to the reporting deficiency and interview during investigation |
| Emily Peraldi | Licensing Program Analyst | Conducted the complaint investigation visit |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation report |
| Cynthia Garcia | Business Office Manager | Participated in physical plant tour and investigation interviews |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 100
Deficiencies: 2
Date: May 24, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation visit triggered by complaints received on 07/13/2020 alleging that facility staff did not provide new facility with resident's personal belongings, did not clean resident's room, and did not provide proper refund. Another complaint alleged that a resident developed pressure injuries while in care and that facility staff did not safeguard resident’s personal belongings.
Complaint Details
The complaint investigation was unannounced and initiated based on complaints received on 07/13/2020. The allegations included failure to provide resident belongings to new facility, failure to clean resident's room, failure to provide proper refund, resident developing pressure injuries, and failure to safeguard resident’s personal belongings. The investigation found the first three allegations unsubstantiated and the last two substantiated. Two citations and civil penalties were issued.
Findings
The investigation found the allegations that facility staff did not clean resident's room, did not provide new facility with resident belongings, and did not provide proper refund to be unsubstantiated. However, the allegation that the resident developed pressure injuries while in care and that facility staff did not safeguard resident’s personal belongings was substantiated. Two citations were issued along with civil penalties totaling $500 for repeated violations.
Deficiencies (2)
Licensee did not provide adequate care and supervision or seek higher level of care to Resident #1 which attributed to sustaining pressure injuries posing an immediate health and safety risk.
Facility failed to safeguard resident's cash, personal property, and valuables, resulting in missing personal care items posing a potential health and safety risk.
Report Facts
Capacity: 100
Census: 54
Civil penalties: 500
Citations: 2
Cost of missing hearing aid: 2700
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Cinthia Garcia | Business Office Manager | Interviewed during investigation and involved in findings |
| Kenneth Mahler | Administrator | Facility administrator mentioned in interviews |
| Kelly Dulek | Licensing Program Analyst | Conducted interviews during investigation |
| Lyndia Sager | Licensing Program Analyst | Conducted interviews during investigation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 100
Deficiencies: 0
Date: May 24, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation following an allegation received on 05/12/2022 that facility staff were not wearing masks.
Complaint Details
The complaint alleged that staff were not wearing masks. After investigation including staff and resident interviews and observations, the allegation was found to be unsubstantiated.
Findings
The investigation found that staff and visitors were observed wearing masks properly, masks were readily available at multiple locations, and staff confirmed training on mask requirements. The allegation that staff were not wearing masks was deemed unsubstantiated.
Report Facts
Staff interviews: 6
Resident interviews: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and subsequent visits |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Cinthia Garcia | Business Office Manager | Met with Licensing Program Analyst during the investigation |
| Kortnie Spitznogle | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 100
Deficiencies: 0
Date: May 6, 2022
Visit Reason
The visit was conducted as a Case Management - Incident investigation following a phone call and incident report received on 05/05/2022 regarding an alleged inappropriate touching between staff and a resident.
Complaint Details
The complaint involved an allegation of inappropriate touching by staff towards a resident. The allegation was investigated through interviews with the Executive Director, involved residents, staff, and witnesses. The complaint was not substantiated as no inappropriate touching was confirmed.
Findings
Interviews with involved parties and staff revealed that the incident involved staff placing a hand on the upper thigh region outside the resident's pants, which made a witness uncomfortable but was considered an innocent act. No inappropriate touching was confirmed, and no citations were issued during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Executive Director | Interviewed regarding the incident and investigation. |
| Angel Ascencio | Licensing Program Analyst | Conducted the Case Management - Incident visit and investigation. |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 100
Deficiencies: 0
Date: Apr 25, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that a resident's apartment was not kept at a comfortable temperature.
Complaint Details
The complaint alleging that a resident's apartment was not kept at a comfortable temperature was investigated and found to be unsubstantiated.
Findings
The investigation found that residents did not experience issues with apartment temperature, and temperature readings in resident rooms and common areas were within the comfortable range of 68 to 85 degrees Fahrenheit. The allegation was unsubstantiated.
Report Facts
Capacity: 100
Census: 56
Temperature range: 68
Temperature range: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation |
| Kortnie Spitznogle | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 100
Deficiencies: 1
Date: Apr 25, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to address allegations that facility staff were not dispensing medication as prescribed, did not notice a change in a resident's condition, and did not allow residents to have guests.
Complaint Details
The complaint investigation was substantiated for the medication dispensing allegation. The other two allegations regarding noticing changes in resident condition and visitation restrictions were unsubstantiated.
Findings
The allegation that facility staff were not dispensing medication as prescribed was substantiated based on record review and observation. The allegations that staff did not notice a change in the resident's condition and did not allow residents to have guests were deemed unsubstantiated due to insufficient evidence.
Deficiencies (1)
Facility staff is not dispensing medication as prescribed
Report Facts
Capacity: 100
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kortnie Spitznogle | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
| Kenneth Mahler | Administrator | Facility administrator mentioned in relation to the investigation |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 100
Deficiencies: 2
Date: Apr 25, 2022
Visit Reason
Unannounced complaint investigation visit conducted to address allegations including staff failing to observe changes in resident's health and facility ant infestation.
Complaint Details
Complaint investigation was substantiated for allegations that staff failed to observe changes in resident's health and that the facility had an ant infestation. Allegations regarding staff not treating residents with dignity and not assisting with ADLs were unsubstantiated.
Findings
The investigation substantiated that staff failed to notify the resident's responsible party and physician of a change in condition, and that the facility had an ant infestation. Other allegations regarding staff not treating residents with dignity and not assisting with ADLs were unsubstantiated due to insufficient evidence.
Deficiencies (2)
Failure to notify resident's responsible party and physician of change in condition, posing potential health and safety risk.
Facility did not assure it remains free of ants, posing potential health risk to residents.
Report Facts
Capacity: 100
Census: 56
Deficiencies cited: 2
Plan of Correction Due Date: May 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kortnie Spitznogle | Executive Director | Met with Licensing Program Analyst during investigation |
| Kenneth Mahler | Administrator | Facility Administrator interviewed regarding findings |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 100
Deficiencies: 2
Date: Apr 25, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to deliver findings related to allegations received on 12/30/2020 regarding personnel training, staffing adequacy, and call light response times.
Complaint Details
The complaint investigation was substantiated. Allegations included personnel not trained for assigned jobs, inadequate staffing to meet resident needs, and resident call lights not being answered timely. Evidence included interviews, staffing records, and call light response data.
Findings
The investigation substantiated all three allegations: personnel were not trained for assigned jobs due to staffing shortages; the facility did not maintain adequate staffing to meet resident needs, with only one caregiver working on multiple occasions; and resident call lights were often not answered timely, with response times exceeding 15 minutes over 100 times in one week.
Deficiencies (2)
Facility personnel were not sufficient in numbers and competent to provide necessary services to meet resident needs, with only one caregiver working on three different dates posing an immediate health and safety risk.
Insufficient food service personnel were employed, trained, and scheduled to meet resident needs; during COVID, the facility had no kitchen staff and untrained management staff prepared food, posing a potential health risk.
Report Facts
Census: 56
Total Capacity: 100
Call light response delays: 100
Call lights marked 'response required but not received': 16
Caregivers working on 12/30/2020 morning shift: 1
Caregivers working overnight shifts: 1
Residents requiring 2-person assist: 3
Residents in facility at time of complaint: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kortnie Spitznogle | Executive Director | Met with Licensing Program Analyst during inspection and provided information about staffing and operations |
| Paul Markovich | Administrator | Provided information regarding staffing shortages and kitchen staff absence |
| Cynthia Garcia | Business Office Manager | Participated in facility tour and staff interviews during prior visits |
| Marta Tapia | Resident Care Director | Participated in facility tour and staff interviews during prior visits |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 100
Deficiencies: 1
Date: Apr 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including that the facility had no administrator and that staff were not providing adequate food service.
Complaint Details
The complaint investigation was initiated based on allegations received on 02/03/2021. The allegation regarding no administrator was unsubstantiated. The allegation regarding inadequate food service was substantiated. A civil penalty was issued and appeal rights were discussed.
Findings
The allegation that the facility had no administrator was deemed unsubstantiated based on interviews and documentation. The allegation regarding inadequate food service was substantiated, with findings that during COVID-19 isolation protocols, residents received cold food that should have been served hot, posing a potential health and safety risk.
Deficiencies (1)
8755(a) General Food Service Requirements were not met as some residents received cold food which should have been served hot, posing a potential health and safety risk.
Report Facts
Capacity: 100
Census: 59
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Paul Markovich | Administrator | Named as the facility administrator at the time of the complaint |
| Kortnie Spitznogle | Administrator | Met with Licensing Program Analyst during the investigation |
| Kelly Newcomb | Resident Service Director | Signed the report as Administrator had to leave the facility |
| Teresa Camara | Licensing Program Analyst | Conducted the complaint investigation |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Named in report signatures |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 100
Deficiencies: 1
Date: Apr 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation triggered by an anonymous tip alleging that the facility failed to handle an outbreak appropriately.
Complaint Details
The complaint was substantiated. The facility failed to handle an outbreak appropriately, including failure to timely report the outbreak to licensing and local health authorities, and inadequate communication with families and staff.
Findings
The investigation substantiated that the facility did not report the outbreak in a timely manner and failed to adequately notify families and authorities. Multiple residents and staff were sick with symptoms over several days, and the facility had communication and reporting deficiencies related to the outbreak.
Deficiencies (1)
The facility did not report an outbreak to the appropriate agencies in a timely manner, posing an immediate health, safety, and personal rights risk to persons in care.
Report Facts
Residents present: 58
Total licensed capacity: 100
Residents sick or with symptoms: 36
Employees sick or with symptoms: 4
Residents with symptoms in memory care: 12
Residents with symptoms on various dates: 37
Staff call-outs: 3
Residents called and documented in memory care: 1
Residents called and documented in assisted living: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Oversaw the investigation and signed the report |
| Kortnie Spitznogle | Administrator | Facility administrator interviewed during investigation |
| JoAnn Rosales | Licensing Program Analyst | Received email notification from Long-Term Care Ombudsman |
| KaSandra Lopez | Licensing Program Analyst | Spoke with Administrator confirming outbreak and follow-up |
Inspection Report
Annual Inspection
Census: 57
Capacity: 100
Deficiencies: 0
Date: Mar 28, 2022
Visit Reason
The visit was a required, unannounced annual inspection with a specific emphasis on infection control practices and procedures.
Findings
The facility was found to be in good condition with clean and appropriately furnished resident bedrooms, sanitary restrooms, and well-maintained common areas. Infection control practices were adequate, including symptom screening, visitor policies, PPE supply, and cleaning protocols. No citations were issued during the visit.
Report Facts
Number of bedrooms: 64
Number of public restrooms: 6
Number of resident bathrooms/showers: 6
Water clearance in fountains: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the inspection and authored the report |
| Kortnie Spitznogle | Administrator | Met with Licensing Program Analyst during the inspection |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 100
Deficiencies: 5
Date: Mar 25, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including resident sustaining a bed sore, medication not administered as prescribed, resident left in soiled clothing, staff not responding to call button, and staff not safeguarding resident's property.
Complaint Details
Complaint investigation was substantiated. Allegations included resident sustaining bed sore, medication not administered as prescribed, resident left in soiled clothing, staff not responding to call button, and staff not safeguarding resident's property. Multiple interviews, record reviews, and observations were conducted between 08/24/2020 and 03/25/2022.
Findings
The investigation substantiated all allegations, finding that the resident sustained pressure injuries while in care, medications were not administered as prescribed, the resident was left in soiled clothing for an extended period, staff failed to respond timely to call button alerts, and resident property was not properly safeguarded. Deficiencies were cited related to care and supervision, observation and documentation, medication administration, call system maintenance, and safeguarding resident property.
Deficiencies (5)
Failure to provide adequate care and supervision resulting in resident sustaining pressure injuries and soiled clothing posing immediate health and safety risks.
Failure to observe, document, and communicate resident's pressure injuries/wounds contributing to untreated injuries.
Failure to provide PRN medications to resident in pain due to lack of authorization and communication with hospice or physician.
Call button system not functioning properly with multiple unresponded alerts posing potential health and safety risk.
Failure to safeguard resident's personal property including medical supplies and electronic items.
Report Facts
Census: 55
Total Capacity: 100
Call button unresponded alerts: 65
Call button alerts with wait time >10 minutes: 175
Deficiency counts: 5
Plan of Correction due dates: Mar 28, 2022
Plan of Correction due dates: Apr 8, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Matthew Girardot | Sales Director | Met with Licensing Program Analyst during inspection and involved in facility tour |
| Paul Markovich | Administrator | Former administrator interviewed regarding allegations |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 100
Deficiencies: 1
Date: Mar 25, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to deliver findings regarding allegations including staff isolating residents from authorized representatives, emotional abuse, creating fictitious medical reasons, mishandling residents, and retaliation against residents.
Complaint Details
The complaint investigation was triggered by allegations received on 05/19/2020 regarding staff isolating residents from authorized representatives, emotional abuse, fictitious medical reasons, mishandling residents, retaliation, and mishandling resident's medication. The medication mishandling allegation was substantiated; others were unfounded.
Findings
The investigation determined that the allegations of isolation, emotional abuse, fictitious medical reasons, mishandling residents, and retaliation were unfounded. However, the allegation of staff mishandling resident's medication was substantiated due to medication errors and documentation issues posing an immediate health and safety risk.
Deficiencies (1)
Failure to assist Resident #1 with medications as prescribed, including administering discontinued medication and missing documentation, posing an immediate health and safety risk.
Report Facts
Capacity: 100
Census: 55
Deficiency count: 1
Plan of Correction Due Date: Apr 8, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Dulek | Licensing Program Analyst | Evaluator who conducted the complaint investigation and authored the report |
| Matthew Girardot | Sales Director | Facility representative met during the inspection |
| Kenneth Mahler | Administrator / Executive Director | Facility administrator mentioned in relation to interviews and document discussions |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 100
Deficiencies: 6
Date: Mar 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-09-02 regarding allegations of neglect, lack of supervision, medication mismanagement, delayed response to call buttons, inadequate food service, and failure to safeguard personal belongings at Pacifica Senior Living Oxnard.
Complaint Details
The complaint investigation was substantiated. Allegations included neglect/lack of supervision causing pressure injuries, failure to seek medical attention, medication mismanagement, delayed response to call buttons, residents left in soiled diapers, inadequate food service, and failure to safeguard personal belongings. One allegation regarding lack of daily activities was unsubstantiated due to COVID-19 isolation orders.
Findings
The investigation substantiated multiple allegations including neglect and lack of supervision resulting in a resident sustaining pressure injuries that went unreported and untreated, failure to seek medical attention, mismanagement of medication, delayed response to call buttons, residents left in soiled diapers, inadequate food service during COVID-19 isolation, and failure to safeguard personal belongings. One allegation regarding lack of daily activities was unsubstantiated due to COVID-19 isolation orders.
Deficiencies (6)
Failure to regularly observe residents for changes in condition and communicate these changes, resulting in untreated pressure injuries.
Failure to provide adequate care and supervision to Resident #1, contributing to pressure injuries.
Failure to contact physician prior to administering PRN pain medication for Resident #1, resulting in untreated pain.
Call button system malfunction and failure to respond to call alerts in a timely manner, posing health and safety risks.
Failure to safeguard residents' personal belongings, including missing personal care items and electronic device.
Failure to provide adequate food service; some residents received cold food during tray service due to COVID-19 isolation.
Report Facts
Capacity: 100
Census: 53
Civil penalty: 500
Call button records pages: 537
Call button response time: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Camara | Licensing Program Analyst | Conducted complaint investigation visits and authored report |
| Jeralyn Ann Pfannenstiel | Licensing Program Manager | Oversaw complaint investigation |
| Kenneth Mahler | Administrator | Facility administrator named in report header |
| Kortnie Spitznogle | Administrator/Executive Director | Met with Licensing Program Analyst during visits |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during visits and informed of civil penalty |
| Sara Gutierrez | Resident Care Director / Facility Administrator | Interviewed regarding care and medication management |
| Lorraine Patterson | Investigator | Conducted interviews and investigation related to complaint |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 100
Deficiencies: 0
Date: Mar 18, 2022
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations that the facility did not provide adequate staff to meet resident needs, did not maintain a sanitary environment, and that a resident required a higher level of care.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included inadequate staffing, unsanitary conditions, and a resident needing higher care. Interviews and observations did not support these claims sufficiently to confirm violations.
Findings
The investigation found the allegations unsubstantiated based on observations and interviews. While some concerns about cleanliness and staffing delays were noted, the facility was generally found to maintain a clean environment and adequate staffing levels. The resident requiring a higher level of care was receiving hospice services and monitored regularly.
Report Facts
Staff members present: 3
Staff members present: 2
Wait time for resident assistance: 10
Wait time for resident assistance: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation |
| Kenneth Mahler | Administrator | Facility administrator during investigation |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Kortnie Spitznogel | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 100
Deficiencies: 0
Date: Mar 18, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-04-02 alleging multiple issues including inappropriate staff communication, unqualified staff, inadequate food provision, and residents being left in soiled diapers for extended periods.
Complaint Details
The complaint included allegations of staff speaking inappropriately to residents, failure to communicate effectively, unqualified staff providing care, inadequate food provision, and residents left in soiled diapers. After investigation including interviews and record reviews, all allegations were deemed unsubstantiated.
Findings
The investigation found all allegations unsubstantiated based on interviews with staff and residents, review of training records, menus, and observations. Staff were found to communicate appropriately, have required training, provide adequate food, and assist residents with toileting needs in a timely manner.
Report Facts
Complaint Control Number: 31
Training hours required: 10
Training hours completed: 9.5
Training hours completed: 12.5
Training hours completed: 4.25
Hands-On Skills training hours: 16
Staff check-in frequency: 3
Wait time for assistance: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted complaint investigation and interviews |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Kenneth Mahler | Administrator | Facility administrator during investigation |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during investigation |
| Kortnie Spitznogle | Administrator | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 100
Deficiencies: 0
Date: Mar 18, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 05/07/2020 regarding a resident being left in soiled diapers for extended periods and staff not giving medication to the resident.
Complaint Details
The complaint was unsubstantiated. Allegations included a resident being left in soiled diapers and staff not administering medication. Interviews with residents, staff, family members, and review of medical and care plans showed no preponderance of evidence to prove the violations occurred.
Findings
The investigation found that staff generally assist residents with toileting needs promptly and that the resident in question was able to self-administer medication. Interviews and documentation reviewed did not substantiate the allegations, and therefore the complaint was unsubstantiated.
Report Facts
Capacity: 100
Census: 53
Complaint Control Number: 29-AS-20200507130645
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Kenneth Mahler | Administrator | Facility Administrator at time of investigation |
| Cynthia Garcia | Business Manager | Met with Licensing Program Analyst during investigation |
Inspection Report
Census: 50
Capacity: 100
Deficiencies: 1
Date: Dec 13, 2021
Visit Reason
The visit was a Case Management - Deficiencies unannounced inspection conducted to review compliance with licensing requirements, specifically focusing on deficiencies related to resident care plans and documentation.
Findings
The inspection found that the facility failed to update the Needs and Service Plan for a resident (R1) after a significant change in condition, including multiple falls and a fractured ankle. This failure to update the plan was cited as a deficiency.
Deficiencies (1)
The pre-admission appraisal was not updated in writing to note significant changes and keep the appraisal accurate, specifically no updated Needs and Service Plan for resident R1 after returning from the hospital.
Report Facts
Deficiencies cited: 1
Plan of Correction Due Date: Dec 24, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kortnie Spitznogle | Administrator | Met with Licensing Program Analyst during inspection |
| Angel Ascencio | Licensing Program Analyst | Conducted the Case Management - Deficiencies visit |
| Kristin Heffernan | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 100
Deficiencies: 0
Date: Nov 10, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation received on 06/05/2020 that a resident sustained an unexplained injury while in care.
Complaint Details
The complaint alleged that a resident sustained an unexplained injury while in care. The investigation involved interviews with staff, residents, responsible parties, and outside agencies on multiple dates and review of facility files. The resident had a skin tear noted around 06/05/2020, but staff were not cooperative and no written statements were found. The resident was on hospice and had multiple falls before moving out and later passing away. The allegation was found unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included multiple interviews and document reviews, concluding that although the allegation may have happened, there was insufficient evidence to prove the violation occurred. Therefore, the allegation was unsubstantiated.
Report Facts
Complaint received date: Complaint received on 06/05/2020
Number of interviews conducted: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Kortnie Spitznogle | Executive Director | Met with Licensing Program Analyst during entrance interview |
| Kristin Heffernan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 100
Deficiencies: 0
Date: Oct 28, 2021
Visit Reason
The inspection was conducted as an unannounced complaint investigation following a complaint received on 2021-05-21 alleging that staff inappropriately restrained a resident while in care.
Complaint Details
The complaint alleged inappropriate restraint of a resident by staff. The investigation found no evidence supporting the allegation, and it was deemed unsubstantiated.
Findings
The investigation included interviews, file reviews, and document analysis, revealing that no residents had been restrained and that restraining is not part of staff training. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Resident Annual Assessments indicating no restraint required: 5
Residents not restrained: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit. |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Kortnie Spitznogle | Facility Administrator met during entrance and exit interviews. |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 100
Deficiencies: 1
Date: Oct 26, 2021
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not responding to residents' calls for assistance in a timely manner.
Complaint Details
The complaint was substantiated based on interviews with residents and staff, review of facility policies, and SMARTcare call logs showing delayed and missed responses to resident calls for assistance.
Findings
The investigation substantiated the allegation that staff did not respond to residents' calls for assistance in a timely manner, with evidence showing residents sometimes waited 20-60 minutes for help and SMARTcare logs indicating 577 calls exceeded a 15-minute response time and 371 calls were not responded to.
Deficiencies (1)
Failure to comply with CCR 87468.1(a)(2) regarding residents' personal rights to safe, healthful, and comfortable accommodations due to untimely staff response to calls for assistance.
Report Facts
Call buttons elapsed past 15 minutes: 577
Calls not responded to: 371
Census: 48
Total capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Kristin Heffernan | Licensing Program Manager | Oversaw the complaint investigation. |
| Kortnie Spitznogle | Executive Director | Met with the Licensing Program Analyst during the investigation. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 100
Deficiencies: 0
Date: Oct 6, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-03-23 alleging that a resident sustained unexplained injuries while in care.
Complaint Details
The complaint alleged that a resident sustained unexplained injuries while in care. The resident had a fall on 2020-03-21 and was receiving hospice services for Alzheimer's Disease. The investigation included interviews with staff and review of facility and hospice records. The resident passed away on 2020-09-20. The allegation was unsubstantiated.
Findings
The investigation found insufficient evidence to prove the alleged violation of staff neglect and lack of supervision. The allegation was determined to be unsubstantiated based on interviews, file reviews, and hospice documentation.
Report Facts
Complaint Control Number: 31-AS-20200323142453
Facility Capacity: 100
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Kristin Heffernan | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Cynthia Garcia | Business Office Manager | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 100
Deficiencies: 0
Date: Aug 12, 2021
Visit Reason
Unannounced complaint investigation visit conducted due to multiple allegations including severe neglect resulting in death of a resident, a resident sustaining a fracture, unsanitary conditions, foul odor, and failure to meet residents' hygiene needs.
Complaint Details
The complaint investigation was triggered by allegations of severe neglect resulting in the death of Resident #1, a fracture sustained by Resident #2, unsanitary conditions and foul odor in Resident #3's room, and failure to meet Resident #3's hygiene needs. After investigation, all allegations were found unsubstantiated.
Findings
All allegations including severe neglect resulting in death, resident fracture, unsanitary room conditions, foul odor, and failure to meet hygiene needs were deemed unsubstantiated based on interviews, document reviews, and observations during the investigation.
Report Facts
Facility capacity: 100
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JoAnn Rosales | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 100
Deficiencies: 0
Date: Aug 12, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that staff were overmedicating residents, medications were not properly stored and locked, and staff were handling residents roughly causing skin injuries.
Complaint Details
The complaint included allegations of overmedicating residents, improper medication storage, and rough handling causing skin injuries. The investigation concluded all allegations were unsubstantiated.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with residents and staff, review of medication and hospital records, and facility observations confirming proper medication storage and no evidence of rough handling causing injuries.
Report Facts
Capacity: 100
Census: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angel Ascencio | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Kristin Heffernan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 100
Deficiencies: 1
Date: Apr 30, 2021
Visit Reason
An unannounced complaint investigation was conducted due to allegations that staff did not deliver mail to residents and opened residents' mail without their consent.
Complaint Details
The complaint was substantiated based on interviews with residents and the administrator. Two of eight residents interviewed were aware of missing packages. The administrator admitted to opening packages and not delivering them, following corporate advice.
Findings
The investigation substantiated the allegations that staff opened residents' packages without consent and did not deliver mail to residents. Interviews revealed that packages addressed to residents were opened by the administrator and not delivered, posing a personal rights risk.
Deficiencies (1)
Violation of CCR 87468.1 Personal Rights of Residents: Residents did not receive unopened correspondence in a prompt manner as packages were opened and not delivered to intended residents.
Report Facts
Census: 47
Total Capacity: 100
Packages delivered: 10
Residents interviewed: 8
Deficiency POC Due Date: Plan of Correction due date was 05/06/2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kasandra Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Sara Gutierrez | Executive Director | Interviewed during investigation; admitted to opening packages |
| Paul Markovich | Administrator | Named as facility administrator |
| Kelly Burley | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 100
Deficiencies: 2
Date: Aug 21, 2019
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that facility staff failed to ensure residents were appropriately dressed (not wearing shoes while walking) and that there was insufficient staffing.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to ensure residents were appropriately dressed and insufficient staffing. The licensee was found to have failed in these areas, resulting in a civil penalty of $250.
Findings
The investigation substantiated the allegations that a resident was observed walking without shoes and that the facility was not sufficiently staffed, posing potential health, safety, and personal rights risks to residents. Civil penalties of $250 were assessed.
Deficiencies (2)
Facility personnel were not sufficient in numbers and competent to provide the services necessary to meet resident needs.
Facility failed to provide ongoing assistance with activities of daily living, as evidenced by a resident walking without shoes, posing a potential safety risk.
Report Facts
Civil penalty amount: 250
Residents in memory care unit: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joann Rosales | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Nichelle Gillyard | Licensing Program Manager | Oversaw the complaint investigation |
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