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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:04:30 PM


Document Has Been Signed on 10/05/2023 02:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 76DATE:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Vanessa JewellTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Tuesday Cabiness and Gina Saucedo conducted an case management visit, in conjunction with complaint number (31-AS-20230928100059). During initial investigation, and from interviews and documentation obtained during the visit, LPAs, determined that the facility did not report an incident of resident #1 (R1) eloping from the memory care unit. LPAs requested copies of the incident report and documentation of the report being faxed to Licensing, and after review, the documentation provided was not valid and the date and time, did not match the incident report. Therefore, LPAs, determine the facility did not report the incident and a citation of failure to report will be issued during this visit.

Exit interview, copy of report, citation issued, and appeal rights provided.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/05/2023 02:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
87211(a)(1)

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Reporting Requirements:Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...
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POC cleared during the visit, SIR was obtained and submitted to LPA.
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This report shall include the resident's name, age, sex and date of admission; date and nature of event..This requirement was not met, evidenced by, based on interviews, facility did not submit an SIR pertaining to R1, who eloped from the memory care unit. This is a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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