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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 07/02/2024
Date Signed: 07/03/2024 03:47:32 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
06/04/2024 and conducted by Evaluator Raymond Comer
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240604154507
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: 72DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Vanessa JewellTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not comply with reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial complaint visit on 6/04/2024. Today, 7/02/2024, LPA conducted a subsequent site visit regarding the allegation listed above.

At 9:30 AM, LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was explained.

Allegation: Staff did not comply with reporting requirements---

It is alleged that Staff were aware of Resident#1 (R1) having sustained an injury, yet Staff did not submit an incident report as neccessary, according to Title 22 reporting requirments. (87211)

[9099 C-Continued]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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 3
Control Number 31-AS-20240604154507
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS
FACILITY NUMBER: 197609103
VISIT DATE: 07/02/2024
NARRATIVE
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To investigate the allegation, LPA obtained and reviewed relevant documents. (Resident Files, Incident Report submissions, Resident roster,and Staff roster.) According to the documents reviewed, on November 3, 2023, Staff informed the Person responsible for R1 of the incident, and filed an incident report to Community Care Licensing, which was sent in a timely manner and according to regulations.

Per Interview with Administrator, Staff were aware of the incident on the day of occurrence and required notifications were submitted. Administrator states that the Responsible Party (RP) for R1 wished to consult with additional family members prior to making any emergency medical treatment efforts. However, the Administrator says they continued on with due diligence to assess and monitor R1's health and pain concerns.

Therefore, the allegation that Staff failed to follow proper reporting requirements is UNSUBSTANTIATED at this time.

No deficiency cited. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
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