197609103-8-23-2023-31-AS-NMAN-CV9NLB-20230901103317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 08/23/2023
Date Signed: 08/23/2023 03:09:40 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
05/13/2022 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20220513091519

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:	11:18 AM
MET WITH:	Gerard Palmos		TIME COMPLETED:	03:12 PM

ALLEGATION(S):

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Resident's needs were not met due to lack of staffing.

Due to neglect in care resident wound got infected.

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 conduct additional interviews and deliver investigative findings. LPA met with staff Gerard Palmos and explained the purpose of the visit.

#1. Resident's needs were not met due to lack of staffing.

It is alleged that the facility did not have enough staff and R1 needs were not met. To investigate the above allegation, LPA requested copies of documents relevant to the investigation at 11:48am. LPA began interviews with the Executive Director (ED) and staff between 12:11pm - 1:25pm. Additional interviews were conducted with residents on 08/23/2023 at approximately 1:10pm between 1:56pm. Interviews with four (04) out of six (06) residents confirm there is sufficient staff to meet their needs and staff is available when needing assistance.
Continued 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-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: 08/23/2023

NARRATIVE

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At the time of the investigation LPA observed the Resident Care Schedule with sufficient staff scheduled to assist residents in care. Based on observations, interviews, and record review there is not enough corroborating evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time.

#2. Due to neglect in care resident wound got infected

It is alleged that resident #1 (R1) had wounds but were uncertain if they caused R1 infection. To investigate the above allegation, LPA requested copies of documents relevant to the investigation including but not limited to the staff and resident rosters, physician reports and hospice records on 05/23/2022 at 11:48am. At the time of the investigation, Interviews with staff revealed that R1 was admitted to Premier Hospice INC for wound care on 11/09/2021. Facility staff provided care for R1 in between their personal care companion and hospice care by providing incontinent care changing, repositioning, and feeding. R1 was being assisted by the hospice agency staff two (02) times per week and (02) times pro re nata (prn). Upon record review of the Premier Hospice Care Outside Agency/Services Documentation R1 was being seen two (02) times a per week for wound care, basic comfort care treatment, and education. In the month of February 2022 R1 was being seen every day by hospice care staff for wound care and hospice care. Based on observations, interviews, and record review there is not enough corroborating 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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