197609103-2-1-2023-31-AS-NMAN-CS5PVM-20230524113923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:44:47 PM

Substantiated

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
01/24/2023 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20230124120222

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: 66	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	10:48 AM
MET WITH:	Gerard Palmos		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Heater not working in residents room.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced initial 10day complaint visit to the facility on 02/01/2023 at 10:48am to investigate the above allegation. Upon arrival LPA Lacy met with Memory Care Director Gerard Palmos and explained the purpose of this visit.

A physical plant tour was conducted at 11:05am.

It is alleged that the heat is not working. To investigate the above allegation, LPA requested documents relevant to the investigation at approximately 11:42am. LPA interviewed staff and residents at approximately 11:45am between 12:50pm. Interviews with staff determined that the 3rd floor is experiencing an issue with the heat as of December 12th, 2022. Four (04) out of eight (08) bedrooms occupied on the 3rd floor are affected by this issue. Interviews with four (04) out of (6) six residents concluded that although the heater is not working properly they have not had any issues with the temperatures in their rooms.
Continued on LIC9099C.

Substantiated

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: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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-20230124120222

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: 02/01/2023

NARRATIVE

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Although during the investigation the facility provided documents identifying that they are working with the vendor to fix the heating system, overall investigation revealed that the facility has had an ongoing issue with the air conditioning/heating system and as per documents, the issues exist from July 2022. The same issue was investigated by the Licensing Department before on 09/23/2022 complaint control #31-AS-20220923103324 and they have failed to correct the problem up to date.
Based on LPAs interviews, record review and observations there is enough evidence to support the allegation, Therefore, allegation is deemed SUBSTANIATED at this time.

Deficiency cited on 9099D.

Exit interview conducted, copy of report and appeal rights issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230124120222

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/15/2023 Section Cited CCR 87303(a)(b)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services...(b) A comfortable temperature for residents shall be maintained at all times. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee will contact corporate and vendor to set a date for repairs to begin and provide to LPA by email by POC due date. Licensee will provide LPA with weekly follow-up reports until completion of work.
	8 9 10 11 12 13 14	During the time of the investigation staff confirmed that the heater is not working on half of the 3rd floor as of 12/12/2022. This may pose a potential Health and Safety risk to persons 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.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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