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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802425
Report Date: 05/18/2026
Date Signed: 05/18/2026 04:21:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2026 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20260427145037
FACILITY NAME:VISTAS AT OXNARD SENIOR LIVING,THEFACILITY NUMBER:
565802425
ADMINISTRATOR:FRANCESCA WESTFACILITY TYPE:
740
ADDRESS:2211 E GONZALES RDTELEPHONE:
(805) 819-2518
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:100CENSUS: 54DATE:
05/18/2026
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Francesca WestTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff do not ensure that residents are administered their medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegation. Upon arrival, LPA met with Executive Director Francesca West and explained the reason for the visit.

On 05/05/2026, between 03:45 p.m. and 5:00 p.m., the LPA interviewed the Executive Director, the Health and Wellness Director, one (1) staff, and obtained copies of resident records and other pertinent documents relevant to the investigation. During today's visit the LPA conducted file review for three (3) residents and interviewed the ED.

Report will continue on LIC9099-C, 2nd page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20260427145037
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VISTAS AT OXNARD SENIOR LIVING,THE
FACILITY NUMBER: 565802425
VISIT DATE: 05/18/2026
NARRATIVE
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Regarding the allegation, “Staff do not ensure that residents are administered their medications as prescribed,” it is the concern of the Reporting Party (RP) that Resident 1 (R1) did not receive their medication from 04/01/2026 – 04/09/2026, or on 1/8, 1/10, 1/13, 1/17, and 1/21/2026. If R1 does not receive their medication, it causes them to decompensate quickly and suffer side effects. It was further reported that Resident 2 (R2) continued to receive medication from September 18, 2025, through March 25, 2026, despite the prescription being discontinued. Lastly, Resident 3 (R3) did not receive their medication sometime in April 2026. To investigate, the LPA conducted interviews and a file review.

During an interview, Executive Director (ED) Francesca West confirmed the allegation. The ED stated that there had been issues obtaining medications for R1 from the pharmacy in April. This was due to the pharmacy rejecting a medication order because it was signed by a nurse practitioner at R1’s primary care provider’s office rather than their psychiatrist’s office. Regarding the missed doses in January, the ED stated that the refill order was pending; however, the medication was documented as administered on the days in between. The ED was unsure why the medication was given on some days and not others, noting that "pending refill" was written on the Medication Administration Record (MAR). The ED also stated that R3 did not receive medication in April due to a pending refill.

Furthermore, the ED confirmed that R2 was receiving medication that had been discontinued in September 2025 until mid-March 2026. The ED stated this was an oversight by the previous Wellness Director, Giovanni Guirra. The ED revealed that facility staff did not bring any of these issues to her attention; instead, she was made aware by the residents’ case manager and states they should of never happened. Once notified of the discrepancies, the ED implemented the following corrective actions: Conducted a Medication Technician in-service training, initiated a new training platform on Relias, met with the pharmacy to troubleshoot the issues and subsequently switched pharmacies for the three residents, implemented a new policy requiring two staff members to review discharge notes and verify that the pharmacy has received all medication orders.

Report will continue on LIC9099-C, 3rd page.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20260427145037
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VISTAS AT OXNARD SENIOR LIVING,THE
FACILITY NUMBER: 565802425
VISIT DATE: 05/18/2026
NARRATIVE
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A review of the MARs for all three residents confirmed that R1 did not receive Clozapine 100 mg on 1/8/26, 1/10/26, 1/13/26, 1/17/26, 1/21/26, and from 4/1/26 to 4/09/26. The MAR review also confirmed that R3 did not receive Clozapine 100 mg on 04/01/26. The LPA observed R2’s After Visit Summary from Community Memorial Brent Neurology on file, dated 9/18/25, which instructed to stop Carbidopa-Levodopa due to drug induced Parkinsonism. The LPA was unable to review R2’s MARs for September and October due to resident was admitted to the facility on 10/08/2025; however, the LPA observed that the MARs from November 2025 to March 2026 reflected that R2 was administered Carbidopa-Levodopa from January 24, 2026 until March 24, 2026. According to the ED, the medication was finally stopped in March when the resident’s case manager informed them it had been discontinued in September 2025. Based on the interviews and record reviews, the statements from the ED and the residents' MARs confirmed the allegation. Therefore, the allegation, “Staff do not ensure that residents are administered their medications as prescribed,” is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was cited during the visit (See 9099-D). Civil Penalty issued for the amount of $250. The ED was informed that failure to correct deficiency may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20260427145037
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VISTAS AT OXNARD SENIOR LIVING,THE
FACILITY NUMBER: 565802425
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2026
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical&Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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The ED stated that all MT's have received corrective action plans, conducted a in service training, switched all three resident pharmacies, and will submit proof of all this to LPA by 05/19/2026.
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Based on interviews and record review, the licensee did not comply with the section cited above, by allowing R1 and R3 missed one or multiple prescribed medications and continuing to administer a discontinued medication to R2 which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4