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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 05/23/2022
Date Signed: 05/23/2022 04:13:25 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
05/13/2022 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20220513091519
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: 61DATE:
05/23/2022
UNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Vanessa JewellTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility did not issue a refund to authorized representative upon resident's death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced initial 10day complaint visit on 05/23/2022 at 11:13am. LPA met with Keith Bernabe and explained the purpose of the visit.

LPA conducted a physical plant tour at 11:26am.

It is alleged that the facility charged $2,200 dollars for an extended level of care while resident #1 (R1) was in the hospital, the charge has not been refunded nor has the remainder of the March rent. To investigate the above allegation, LPA requested copies of documents relevant to the investigation at 11:48am. LPA began interviews with Executive Director (ED) and staff between 12:11am and 1:25pm. During the investigation staff#1 (S1) confirmed that the facility refunded R1’s Power of Attorney (POA) a prorated amount of rent for last two (02) days of March 2022 for the level of care and room and board. The (02) day refund was issued due to prior 30-day notice issued by the R1’s POA, which was effective on 03/28/2022.
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
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 4
Control Number 31-AS-20220513091519
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: 05/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2022
Section Cited
HSC
1569.652(a)
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1569.652 Termination of admission agreement upon death of resident...(a)A residential care facility for the elderly shall not require advance notice for terminating an admission agreement upon the death of a resident...

This requirement is not met as evidenced by:
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Licensee will provide in writing to R1's POA a break down of the amount and justification of the refund due. Licensee will submit to LPA by email, a copy of the letter to R1's POA and a copy of the check issued in the correct amount by POC due date of 06/07/2022.
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The Licensee did not ensure the facility issued a refund in the correct amount. R1's POA received a refund for a level of care and 2 pro rated days for the month of March. This may pose a potential Health and Safety risk to clients in care.
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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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20220513091519
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: 05/23/2022
NARRATIVE
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R1 went to the hospital and passed away before the 30-day notice was due. Upon review of facility records LPA noted that R1 expire on 03/14/2022. R1’s admission agreement section VIII letter C indicates the following: “This agreement shall terminate automatically upon your death”. LPA observed an email correspondence from facility staff to R1’s POA, that R1’s room had been completely cleared out on 03/09/2022 at 3:10pm. Based on LPAs interviews, record review and observations there is enough evidence to support the allegation, Therefore, allegation is deemed SUBSTANIATED at this time.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4