197609103-8-23-2023-31-AS-NMAN-CV9NU7-20230901104551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 08/23/2023
Date Signed: 08/23/2023 03:01:09 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
04/28/2023 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20230428113611

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: 74	DATE:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	02:17 PM
MET WITH:	Gerard Palmos		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff do not ensure emergency lighting is available in the facility during an emergency.

Facility staff are not properly assisting resident during meal periods.

Resident sustained injuries due to staff neglect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted a subsequent complaint visit for the above allegation on 08/23/2023 at 11:09am to deliver investigative findings. LPA Lacy met with staff Gerard Palmos and explained the purpose of the visit.

#1. Facility staff do not ensure emergency lighting is available in the facility during an emergency.

It is alleged that the facility did not have appropriate emergency lighting for residents. To investigate the above allegation LPA requested and obtained copies of facility files and documents including but not limited to staff and resident rosters, and retail store receipts at 11:52am. LPA interviewed Administrator and staff at approximately 12:03pm. Additional staff and resident interviews were conducted between 1:49pm to 3:00pm. Interviews with five (05) out of seven (07) residents affirm the facility provided emergency lighting during the blackout. They were provided flashlights and additional lighting was
Contiunued on LIC9099C.

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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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-20230428113611

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: 08/23/2023

NARRATIVE

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provided in the hallways. During the investigation LPA observed the facility emergency kit storing a sufficient quantity of multiple lighting devices, portable floor and handheld flashlights, LED push lights, motion sensor lights and extra batteries. Based on observations, and interviews there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

#2. Facility staff are not properly assisting resident during meal periods.

It is alleged that resident #1 (R1) is falling asleep during meals. To investigate the above allegation LPA conducted interviews with the Administrator and staff at approximately 12:03pm. Additional staff and resident interviews were conducted between 1:49pm to 3:00pm. Interviews with staff confirm they provide standby assistance by standing or sitting with residents, some can feed their self but may require prompts to remind them to eat. During the investigation, LPA observed three (03) residents that require standby assistance for meals seated at one table. One (01) staff member was seated at the table queuing and assisting residents during mealtime. Two (02) out of (03) residents were observed being prompted by staff to eat and staff performed assistance with feeding to (01) out of (03) residents. Based on observations, and interviews there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

#3. Resident sustained injuries due to staff neglect.

It is alleged that resident #1 (R1) showed signs of "two big bruises on their forehead." To investigate the above allegation LPA conducted interviews with the Administrator and staff at approximately 12:03pm. Additional staff and resident interviews were conducted between 1:49pm to 3:00pm.

Continued on LIC9099C.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230428113611

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: 08/23/2023

NARRATIVE

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Interviews with staff affirm that R1 is confused and disoriented at times and wanders at night and has difficulty sleeping during the night, but had not experienced any falls or injuries. At the time of the investigation LPA observed R1s physician report that identifies they are confused/disoriented and has wandering and sundowning behavior. Based on observations, and interviews, and record review there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards are noted during this visit.

No deficiencies cited. Exit interview conducted and 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: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

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