197609103-8-16-2023-31-AS-NMAN-CUY2Q6-20230822173524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 08/16/2023
Date Signed: 08/16/2023 05:16:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
08/09/2023 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20230809150735

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: 32	DATE:	08/16/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Maria Roleda, Resident Service Director		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff over medicated a resident in care.

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint investigation for the above noted allegation. LPA met with Maria Roleda, Resident Service Director. The purpose of the visit was discussed.

It was reported that staff over medicated a resident in care. To investigate this allegation, on 8/16/2023
between 2:15pm and 2:30 pm, LPA requested documentation that is relevant to the investigation. In addition,
between 2:30pm and 3:00pm, LPA conducted a physical plant tour of the memory care unit. During the tour, LPA observed a table whose paint was chipped and two patio cushions that were stained. LPA notified staff and they immediately removed the table and called housekeeping to clean the cushions.

See 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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-20230809150735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS	FACILITY NUMBER: 197609103
	VISIT DATE: 08/16/2023

NARRATIVE

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Between 3:00pm and 4:00pm, LPA conducted records review. Documents revealed that Resident #1 (R1) has not been given the alleged medication for over a month. Furthermore, the medication is administered in gel form and not pill form. It is prescribed as needed.

Between 4:15pm and 4:35pm, staff interviews were initiated. Interviews revealed that R1 is confused and delusional at times. R1 has delusions of persecution and can be aggressive sometimes towards staff and residents. Per interviews, R1 has not been aggressive lately, therefore the medication has not been needed to be administered. R1 is re-directed when behavioral issues arise and medication is given only if necessary.

Based on interviews and record review, there is not sufficient information to support this allegation. Therefore, the allegation that staff over medicated a resident in care is UNSUBSTANTIATED at this time.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC9099 (FAS) - (06/04)

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