197609103-10-5-2023-31-AS-TAGD-DDFPJ9-20250131102103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:16:29 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
09/28/2023 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230928100059

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: 76	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Residents wandered away due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Tuesday Cabiness and Gina Saucedo conducted a complaint investigation for the allegation mentioned above. LPAs met Administrator Vanessa Jewel and informed her the reason of the visit.

Due to the recent COVID outbreak at the facility, LPAs were not able to conduct a physical plant inspection, nor interview residents and staff. LPA was able to interview the Administrator, and obtain and review documents pertaining to the complaint. Based on the interviews, it was revealed that resident #1 (R1) eloped from the memory care unit in the early morning on 09/21/2023. Staff contacted the Administrator, family member and the police. It was reported that R1 was missing for several hours, and was returned to the facility by the police. It was also revealed, that staff did not ensure the elevator was properly secured and locked. This is a potential health and safety risk to residents in care. Therefore, the allegation resident wandered away due to lack of supervision, is deemed Substantiated. Exit interview, copy of report, appeal rights and citation provided.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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-20230928100059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS	FACILITY NUMBER: 197609103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/12/2023 Section Cited CCR 87705(k)(6)	1 2 3 4 5 6 7	Care of Persons with Dementia:(k)The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: (6) Without violating Section 87468, Personal Rights, facility staff	1 2 3 4 5 6 7	Administrator AGREED to submit in-service training to LPA by POC date.
	8 9 10 11 12 13 14	shall ensure the continued safety of residents if they wander away from the facility. This requirement was not met, evidenced by, during interviews, R1 eloped from the memory care unit, due the elevator not being locked and secured. This is a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

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