197609103-9-30-2022-31-AS-RRAZ-CJYKE4-20221007074943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 09/30/2022
Date Signed: 09/30/2022 02:34:57 PM

Unsubstantiated

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
09/23/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220923103324

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: 63	DATE:	09/30/2022
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Vanessa Jewel		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not providing residents with an adequate quantity of food.
Facility air condition is not in proper working condition in resident's room.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPAs) LaQueena Lacy and Gary Tan conducted an unannounced initial 10day compliant visit to the facility on 9/30/2022 at approximately 10:40am to investigate the above allegations. Upon arrival LPAs met with Executive Director Vanessa Jewell and explained the purpose of this visit.

LPA conducted a physical plant tour at 10:52am.

It is alleged that the facility runs out of food items and provide no choices. To investigate the above allegations LPAs observed the current lunch and alternate menu posted in the dining room, elevator and throughout the facility. LPAs witnessed food being served from the menu of the day and items served from the alternate menu and a sufficient number of staff assisting with meal serving. During the investigation interviews with six (06) residents confirmed the food provided has nutrition is adequate well balanced and sufficient.
Continued on LIC809C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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 2

Control Number 31-AS-20220923103324

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: 09/30/2022

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
26
27
28
29
30
31
32

They do not wait an extended period of time to be served for meals, they are aware of the alternate menu and second food portions being served if asked. Upon document review of the facility menus, a variety of options are listed and provided to residents. Based on observations, interviews and record review, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

#2. Facility air condition is not in proper working condition in resident's room.

It is alleged that there is no air system working on the 3^rd, 4th, and 6th floor rooms. To investigate the above allegation, LPAs interview with ED confirmed the facility had an issue with the air conditioning system only on the 3rd floor on 09/03/2022. Staff #1 (S1) confirmed that the 3rd floor was experiencing an issue with the air conditioning and the facility provided portable air conditioners to those residents and put in a service contact for repairs. During the investigation LPAs checked the thermostat on the 3^rd, 4^th, and 6^th floors to have a temperature measured within the regulatory range verified by using a Ryobi Infrared Thermometer. LPAs inspected seven (7) random rooms and observed portable air conditioners located in all rooms with the temperature measuring within the regulatory range. Upon record review the facility provided a purchase receipt for portable air conditioners on 09/03/2022 from The Home Depot, and a service report from NSWC Mechanical Service dated 09/16/2022 for repairs and worked started on 09/20/2022 and is ongoing. Based on observations, interviews and record review, there is not enough evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted and a copy of report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2