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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 02/26/2024
Date Signed: 02/03/2025 09:06:10 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
02/20/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20240220103619
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: 73DATE:
02/26/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Vanessa Jewel- Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are not dispensing medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Mariana Agban conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with the Executive Director Vanessa Jewell and explained the reason for the visit.

At 10:40 AM, LPA requested resident and staff roster. At approximately 11:30 AM, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. Between 12:00 AM – 1:30 PM, LPA conducted an interview with the Administrator, one (1) staff member and eight (8) residents.
Allegation: Staff are not dispensing medication as prescribed.
It was alleged that staff has not been providing the correct dose of medication.
( Continue on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
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-20240220103619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS
FACILITY NUMBER: 197609103
VISIT DATE: 02/26/2024
NARRATIVE
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LPA reviewed medications and medications records and observed that R1 missed a dose of METFORMIN 500 MG on February 18, 2024. Interview with S1 and S2 revealed that R1 has been transferred from out of state facility without having the appropriate amount of medication supplies. R1's insurance refused to refill the medications until R1 sees southern CA doctor and establish residency. S1 enrolled R1 to AAA Care Pharmacy (facility's pharmacy) to get R1 medications. S2 stated that on 2/18/24 R1 missed the medication due to delay of medication delivery. LPA asked if there was an incident report sent to CCLD. S2 admitted that there was no Incident Report sent to CCLD. Based on interviews and record reviews, the allegation is deemed Substantiated at this time.

Exit interview conducted, Citation issued and Copy of this report delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20240220103619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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: 02/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/05/2024
Section Cited
CCR
80061(e)
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Reporting Requirements. Resident authorized representatives, if any shall be sent any required reports. Licensee failed to provide an SIR regarding missed medication dose. This poses a potential health and safety risk to residents in care.
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Administrator will sent an SIR by the POC date
Type B
03/05/2024
Section Cited
HSC
87465(a)(4)
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The licensee shall assist residents with self-administered medications as needed.Based on the record review the licensee did not comply with the section cited above. LPA observed missed dose of METFORMIN on 02/18/24. This poses a potential health and safety risk to resdients in care.
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Administrator agreed to provide In service training to prevent any future missed medication dosages. Administrator will email LPA proof of training by the POC date
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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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
02/20/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20240220103619

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: 73DATE:
02/26/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Vanessa Jewel- Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff do not respond to resident call buttons in timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Mariana Agban conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with the Executive Director Vanessa Jewell and explained the reason for the visit.

Allegation: Staff do not respond to resident call buttons in timely manner
It was alleged that R1 had an incident of choking and called the emergency call button. Interview with S1 and S2 revealed that there was no witnesses of that incident. S1 stated that S4 checked on R1 when R1's POA asked for help and R1 was okay and there was no sign of choking. LPA have asked 2 residents to test the emergency call button and within 5 minutes or less staff was present in the room. In addition, S1 stated that the facility has done in service training regarding calls acknowledgements on 2/13/24. LPA obtain copy of the in service training. Based on observations, interviews and record reviews, this allegation deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report delivered.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4