197609103-8-24-2021-31-AS-NMAN-C6F3KP-20210831181927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 08/24/2021
Date Signed: 08/24/2021 01:24:31 PM

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
06/05/2020 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20200605113900

FACILITY NAME:	PACIFICA SENIOR LIVING HOLLYWOOD HILLS		FACILITY NUMBER:	197609103
ADMINISTRATOR:	MCCOLL, CAROLINE		FACILITY TYPE:	740
ADDRESS:	1745 N GRAMERCY PLACE		TELEPHONE:	(323) 467-3121
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90028
CAPACITY:	120	CENSUS: 42	DATE:	08/24/2021
		UNANNOUNCED	TIME BEGAN:	11:53 AM
MET WITH:	Vanessa Jewell, Administrator		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility is charging for services not provided

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a subsequent complaint visit to the facility. LPA met with the Executive Director (ED) and explained the purpose of this visit.

It was alleged that the facility charged a $2,000.00 fee for Resident #1 (R1) and then refused to admit the resident.

The investigation of the above noted allegation was conducted by LPAs Naira Margaryan and Rosaura Valenzuela.

During this investigation on 06/12/2020 at 9:15am LPAs spoke with Executive Director Caroline McColl and at 1:30pm LPAs spoke with the Marketing Director. Interviews revealed that the marketing director met R1's family on 02/12/2020, at which time a $2,000.00 community fee was paid to the facility.
See 812-c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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-20200605113900

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: 08/24/2021

NARRATIVE

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Between 02/12/2020 and 06/08/20, due to a health condition, R1 was staying at a skilled nursing facility. On 06/08/2020, R1 was ready to be discharged from the hospital. However, at the time of discharge R1 was not accepted to the facility due to changes in their health condition. As per ED a refund of the $2,000.00 community fee was processed on 08/10/2020.

A review of the documents conducted on 08/20/2021 at 12:00pm verified the information revealed from the interviews.

Based on the information received from the interviews and record review, there is no sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazard is noted during this visit.

Exit interview was conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC9099 (FAS) - (06/04)

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