Inspection Reports for The Vistas at Oxnard Senior Living

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.

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.

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.

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.

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.

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.

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.

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.

The visit was conducted to verify the Chapter 7 Bankruptcy Report filed by Pacifica Senior Living as reported by the media.

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.

The visit was a required, unannounced annual inspection conducted by Licensing Program Analysts to ensure compliance with Title 22 Regulations.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not administer medication as prescribed.

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.

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.

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.

The investigation found that the resident's family was responsible for medical appointments and communication with the physician, and the allegations were deemed unsubstantiated.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were not properly trained for disaster plans.

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.

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.

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.

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.

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.

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'.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced continuation of the required annual inspection to evaluate compliance with licensing regulations.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-09-18 alleging that the facility is understaffed.

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.

The complaint alleging understaffing was substantiated based on review of staff schedules and administrator confirmation of staffing issues during night shifts.

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.

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.

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.

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).

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.

The visit was triggered by a complaint investigation with complaint control number 29-AS-20231012084108.

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.

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.

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.

A case management visit was conducted to address deficiencies observed during a facility tour at Pacifica Senior Living Oxnard.

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.

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.

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.

The complaint investigation was substantiated for improper PPE use during a COVID-19 outbreak and unsubstantiated for medication administration allegations.

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.

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.

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.

Unannounced complaint investigation visit conducted due to an allegation that staff neglected a resident while in care.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that staff failed to provide adequate food service at the facility.

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.

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.

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.

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.

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.

The visit was a Case Management - Deficiencies unannounced inspection conducted to evaluate compliance with care standards and safety regulations.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was conducted as a complaint investigation regarding an allegation that a resident's room had mold.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 04/25/2022 regarding inadequate food service at the facility.

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.

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.

The inspection visit was an unannounced Case Management-Deficiencies inspection conducted due to deficiencies observed during the investigation of complaint control #29-AS-20230123143000.

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.

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.

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.

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.

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.

The inspection was an unannounced required annual visit to evaluate compliance with Title 22 Regulations and ensure the facility meets health and safety standards.

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.

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.

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.

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.

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.

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.

Unannounced complaint investigation visit conducted due to an allegation that the licensee is not keeping the facility free of rodents.

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.

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.

The visit was an unannounced Case Management - Other visit to ensure that an excluded individual is not employed at the facility.

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.

The inspection visit was conducted due to deficiencies observed during the investigation of complaint control #29-AS-20230119090203.

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.

The visit was triggered by deficiencies observed during the investigation of complaint control #29-AS-20230119090203.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 06/07/2022 regarding insufficient staffing and unmet resident incontinence needs.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was conducted as an unannounced complaint investigation following an allegation received on 05/12/2022 that facility staff were not wearing masks.

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.

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.

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.

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.

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.

An unannounced complaint investigation was conducted regarding an allegation that a resident's apartment was not kept at a comfortable temperature.

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.

The complaint alleging that a resident's apartment was not kept at a comfortable temperature was investigated and found to be unsubstantiated.

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.

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.

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.

Unannounced complaint investigation visit conducted to address allegations including staff failing to observe changes in resident's health and facility ant infestation.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation triggered by an anonymous tip alleging that the facility failed to handle an outbreak appropriately.

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.

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.

The visit was a required, unannounced annual inspection with a specific emphasis on infection control practices and procedures.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The complaint alleged inappropriate restraint of a resident by staff. The investigation found no evidence supporting the allegation, and it was deemed unsubstantiated.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The complaint included allegations of overmedicating residents, improper medication storage, and rough handling causing skin injuries. The investigation concluded all allegations were unsubstantiated.

An unannounced complaint investigation was conducted due to allegations that staff did not deliver mail to residents and opened residents' mail without their consent.

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.

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.

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.

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.

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.

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