197609103-6-29-2021-31-AS-MBEY-C4ARM3-20210624130806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 06/24/2021
Date Signed: 06/29/2021 02:33:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PACIFICA SENIOR LIVING HOLLYWOOD HILLS		FACILITY NUMBER:	197609103
ADMINISTRATOR:	VANESSA JEWELL		FACILITY TYPE:	740
ADDRESS:	1745 N GRAMERCY PLACE		TELEPHONE:	(323) 467-3121
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90028
CAPACITY:	120	CENSUS: 34	DATE:	06/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	01:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Martina Berry conducted an unannounced required annual inspection at 9:30 AM. The LPA met with Executive Director Vanessa Jewell to explain the reason for the visit and conduct an entrance interview. The facility currently has 34 total residents in care with 17 residents residing in memory care. The LPA conducted a physical plant tour of all areas including, but not limited to, common areas, kitchen, common bathrooms, medication room, and storage areas. One central entry point has been designated for universal screening. The screening area includes a sign-in log, temperature check, sanitizing station, and visitor questionnaire. Signs have been posted at the facility entrance and throughout the facility regarding infection control procedures. The facility has designated visitation areas. The facility has a scheduling policy for visitors. Visits with parties of four or more are allowed outdoors while smaller parties may visit in resident rooms or designated indoor areas. Hand sanitizing stations are located throughout the facility. Sinks in common restrooms are well stocked with liquid soap for hand washing and paper towels for hand drying. High traffic common areas are cleaned and disinfected at least once each shift. The facility's dining areas have been arranged to observe distancing requirements. The facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. The facility's mitigation plan was approved by CCLD on 2/6/2021. The facility's Emergency Disaster Plan is current and all required areas are completed. All residents are fully vaccinated. Facility policy requires COVID-19 vaccination prior to admission to ensure the health and safety of all residents. Residents are notified about infection control practices by information posted throughout the facility. This information is updated as new information is received from Community Care Licensing Division (CCLD) and public health agencies. Residents are regularly observed for changes in functioning. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS	FACILITY NUMBER: 197609103
	VISIT DATE: 06/24/2021

NARRATIVE

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All facility staff are fully vaccinated. COVID-19 testing is conducted weekly, testing 25% of all staff during each testing period on a rotating basis. Staff are required to provide a current COVID-19 negative test result prior to starting employment. All staff have received COVID-19 fit testing. Staff are informed about COVID-19 procedures and updates through monthly meetings and postings located in the staff area.

The facility has specific procedures for isolation and quarantine of residents in accordance with CCLD and public health guidance. A wing of the facility, located on the first floor, has been designated to temporarily accommodate residents that are symptomatic, waiting for test results, or have tested positive for COVID-19. Resident rooms in this area are private. PPE carts and trash bins with lids are provided for each isolation room. This wing has a separate entrance and exit for staff assigned to this area. Residents in this area are monitored by staff at least every 4 hours. Meals and medication are delivered to residents in isolation. A plan has been developed to ensure appropriate cleaning of isolation rooms. The facility has a sufficient supply of PPE. PPE inventory is conducted at least every 60 days and additional supplies are ordered as needed.

No deficiencies cited. The LPA met with Executive Director Vanessa Jewell to review the report and conduct an exit interview. A copy of this report was provided to the Executive Director via email.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Martina Berry	TELEPHONE: (661) 361-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC809 (FAS) - (06/04)

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