197609103-8-5-2021-31-AS-NMAN-C6E2VW-20210830174438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 08/05/2021
Date Signed: 08/05/2021 12:22:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/05/2020 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20200805164022

FACILITY NAME:	PACIFICA SENIOR LIVING HOLLYWOOD HILLS		FACILITY NUMBER:	197609103
ADMINISTRATOR:	MCCOLL, CAROLINE		FACILITY TYPE:	740
ADDRESS:	1745 N GRAMERCY PLACE		TELEPHONE:	(323) 467-3121
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90028
CAPACITY:	120	CENSUS: 38	DATE:	08/05/2021
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Vanessa Gewell, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Unqualified staff providing residents care

Staff left resident on the floor for extended period of time

Facility is short staffed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit to the facility to deliver a final investigation report of the above noted allegations. The investigation of this complaint was conducted by LPA Naira Margaryan.

During this investigation on 08/10/2020 at 1:15pm, LPA Margaryan spoke to the Executive Director and other facility staff. Interviews revealed that currently the facility has a total of 13 residents in memory care and assisted living units. There are three (03) caregivers and one (01) med tech working each shift. Each caregiver has assigned duties to assist specific residents. In addition, the staff working at the dietary department are cross trained to assist residents as well in case the facility has staff shortage. During the night shift there are two (02) caregivers working on each floor.

On 08/11/2020, LPA Margaryan reviewed staff schedule and facility residents' roster. As per record review the facility has sufficient qualified staff to assist facility residents. See 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200805164022

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/05/2021

NARRATIVE

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Based on interviews and record review, there is no sufficient information to support the allegation. Therefore,
the allegation is UNSUBSTANTIATED at this time.

Staff left resident on the floor for extended period of time. It was reported that a resident passed away and was lying on the floor in their room for hours. During the investigation on 08/11/2020, LPA Margaryan spoke with the Executive Director and other facility staff. Interviews revealed that on 06/22/2020 around 9:00pm, during routine rounds, that Resident #1 (R1), residing in the Assisted Living (AL) section, was found on the floor by the staff. R1 was alert and responsive. 911 was called and R1 refused to go to the hospital. On 06/23/2020, at 2:30am, R1 was found in their bed unresponsive. 911 was called and at 2;40am, R1 was declared expired due to natural causes.

On 07/18/2020 at 3:00pm, LPA Margaryan reviewed R1's facility file and other records. The information revealed from the documents verified the information provided by the facility staff.

Based on interviews and record review, there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Exit interview was conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC9099 (FAS) - (06/04)

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