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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 06/16/2022
Date Signed: 06/16/2022 04:19:31 PM


Document Has Been Signed on 06/16/2022 04:19 PM - It Cannot Be Edited

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 HILLSFACILITY NUMBER:
197609103
ADMINISTRATOR:VANESSA JEWELLFACILITY TYPE:
740
ADDRESS:1745 N GRAMERCY PLACETELEPHONE:
(323) 467-3121
CITY:LOS ANGELESSTATE: CAZIP CODE:
90028
CAPACITY:120CENSUS: 59DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Vanessa JewellTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at 10:43am on 06/16/2022 to
conduct a One (1) year Required Infection Control visit. LPA meet with Vanessa Jewell and
explained the purpose of this visit. The facility has an approved mitigation plan on file.

A tour of the physical plant was conducted at 10:55am with Gerard Palmos and the following was observed:

The facility has a fire clearance for one hundred ten (110) non ambulatory and ten (10) bedridden
with a hospice waiver for (10). The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette, and physical distancing) posted. The PPE screening station is located at the receptionist desk upon entry equipped with sufficient PPE readily accessible, thermometer,hand sanitizer, gloves, mask, and sign in sheet at the time of visit. The facility maintains a temperature at 76 degrees Fahrenheit. The facility has fire extinguishers located throughout the facility to be full and current. The facility has 6 floors with a penthouse. The 2nd, 3rd and 5th floors currently are occupying positive covid-19 residents, these areas were observed to have the appropriate signage with PPE stations and trash cans located outside of the isolation rooms.

Kitchen: At 11:01am LPA observed the kitchen to be clean and free from obstruction. Appliances observed to be in good repair. At 11:04am LPA observed sharps to be located and hanging on the wall in the kitchen inaccessible to residents. LPA observed the refrigerators and freezers to be stocked (fresh fruit, fresh vegetables, meats cheese, dairy, desserts etc. ) with a variety and sufficient perishable and non-perishable food. The pantry was observed to have sufficient supply quantity (dry food, rice, canned fish, vegetables, etc.) of canned and dry foods.

Continued on LIC809C

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 06/16/2022
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Bedrooms: At 11:27am LPAs were able to observe seven (07) random rooms from the remaining floors that are not occupying positive covid-19 residents. All bedrooms observed to be appropriately furnished with
sufficient lighting. LPAs observed appropriate bed linen and comforters on all beds. All bedrooms observed to be clean and clear from obstruction.
Bathroom: At 11:27am LPAs observed (07) bathrooms located in the bedrooms. LPAs observed appropriate grab bars located in the shower and around the toilet. The water temperature measured in range of 112.6 between 119.4 degrees Fahrenheit. Non-skid mats were located in the shower. Bathrooms are stocked and equipped with soap and paper towels. Hand towels are not shared.
Laundry Room: At 11:42am LPAs observed the laundry room located across from the salon on the fourth floor residents have access to the laundry area to do their own laundry, clean and clear from obstruction and storing laundry supplies.
Medications: LPA observed three (03) medication carts at 12:17pm stored in the medication room on the second floor to be locked and storing medication and inaccessible to residents. The refrigerator observed to be doubled locked storing narcotic medications. The facility has (02) first aid kits located in the medication room.
Living, dining room and common areas: At 12:34pm LPAs observed these areas to be appropriately
furnished with tables and chairs and adequate lighting. Observed to be neat and clean. The facility has a gym on the sixth floor currently closed at the time of inspection. The theater located on the 3rd floor also closed at the time of inspection. LPAs observed (02) outdoor patio areas, one located outside the dining room, the second in the front area of the facility, and the surrounding grounds of the facility which was clean and clear from debris and obstruction. These areas are equipped with owing and tables with chairs for seating and additional tables and chairs for lounging. LPAs observed a Fire Department Fire Protection Equipment Performance Report dated 03/01/2022 to have passed, the fire alarm system was tested and observed to be working, it is hard wired and interconnected throughout facility. The facility has fire sprinklers throughout the facility. The facility has a basement with an office for the maintenance director. The space is occupying construction supplies, extra walkers, ladders, files, decorative supplies etc. No bodies of water observed or located on the premises.

No deficiencies cited, exit interview conducted, and a copy of report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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