197609103-5-5-2023-31-AS-NMAN-CV9NU8-20230901104551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 05/05/2023
Date Signed: 05/05/2023 03:48:13 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
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: 76	DATE:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	10:54 AM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are not providing non-slip mats for resident's showers.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced initial 10day complaint visit on 05/05/2023 at 10:54am. LPA met with Administrator Vanessa Jewell and explained the purpose of the visit.
LPA conducted a physical plant tour at 11:03am.
It is alleged that resident # 1 (R1) has never had a non-slip mat in their shower. LPA requested and obtained copies of facility files and documents including but not limited to staff and resident rosters 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. During the investigation the administrator and staff confirmed they do not provide non-slip mats to residents. LPA observed thirteen (13) random bedrooms and two (02) out of (13) were observed to have a two (02) non-slip mats in the bathroom shower.
Based on inspection, observations and interviews there is enough evidence to prove the alleged violation did occur, therefore the allegation is SUBSTANTIATED at this time.
No health and safety hazards are noted during this visit. Deficiency cited, Exit interview conducted, and copy of report and appeal rights issued.

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: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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 3

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2023 Section Cited CCR 87303(a)(5)	1 2 3 4 5 6 7	87303Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...(5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee will chase non-slip mats for all bathroom showers and provide invoice to LPA by email by POC due date.
	8 9 10 11 12 13 14	During the time of the investigation LPA observed thirteen (13) random bedrooms and two (02) out of (13) were observed to have two (02) non-slip mats in the bathroom shower 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: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3