197609103-5-7-2023-31-AS-NMAN-CWBLNZ-20231005085511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 05/07/2023
Date Signed: 05/07/2023 04:18:13 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
02/21/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230221085616

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:	05/07/2023
		UNANNOUNCED	TIME BEGAN:	08:17 AM
MET WITH:	Maria Roleda		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not safeguard the residents personal belongings while in care.
Staff left a resident soiled for extended periods of time while in care.
Resident sustained an injury from a fall while in care.
Facility has insufficient staffing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with the Resdient Services Coordinator, Maria Roleda, and explained the reason for the visit. The Administrator designated Maria Roleda to sign and accept this report.

---Staff did not safeguard the resident personal belongings while in care.

It was alleged that resident’s watch and jewelry have gone missing. To investigate the allegation, on 02/22/2023, LPA requested documents at 10:45 AM, interviewed four (04) staff between 10:45 AM to 11:30 AM and on 05/07/2023, LPA interviewed six residents from 11:00 AM – 12:30 PM and other parties from 1:00 – 1:30 PM. The facility’s Internal Incident Report log and the Department’s Incident Reports do not show incidents related to missing belongings.
(CONT. LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2023

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 4

Control Number 31-AS-20230221085616

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: 05/07/2023

NARRATIVE

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During interviews with staff, all staff stated that they are not aware of any reports of missing belongings. During interviews with residents, all residents stated that they are not missing any belongings. During interviews with other parties, they stated that they do not wish to disclose the name of the resident or share any other details at this time.

Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Staff left a resident soiled for extended periods of time while in care.

It was alleged that diaper on resident was not being changed frequently, poop was falling out and not cleaned for multiple days. To investigate the allegation, on 02/22/2023, LPA conducted physical plant tour at around 10:00 AM, interviewed four (04) staff between 10:45 AM to 11:30 AM and on 05/07/2023, LPA interviewed six residents from 11:00 AM – 12:30 PM and other parties from 1:00 – 1:30 PM. During the physical plant tour, LPA did not observe any soiled residents, soiled beds and did not experience any malodor. During interviews with staff, Staff #2 (S2) stated that residents are checked on every two hours for incontinent care and residents are not left soiled for an extended time. During interviews with residents, all residents stated that they are checked on frequently and are not left soiled for an extended time. During interviews with other parties, they stated that they do not wish to disclose the name of the resident or share any other details at this time.

Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Resident sustained an injury from a fall while in care.

It was alleged that resident fell and had bruise on right arm. To investigate the allegation, on 02/22/2023, LPA requested documents at 10:45 AM, interviewed four (04) staff between 10:45 AM to 11:30 AM and on 05/07/2023, LPA interviewed six residents from 11:00 AM – 12:30 PM and other parties from 1:00 – 1:30 PM. The facility’s Internal Incident Report log and the Department’s Incident Reports do not show incidents related to a fall that resulted in a bruise on right arm.
(CONT. LIC9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20230221085616

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: 05/07/2023

NARRATIVE

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During interviews with staff, Staff #1 (S1) stated that facility has had fall incidents, but no one has complained to S1 as of late. Staff #2 (S2) stated that they are not aware of any fall complaints and that falling is something the facility tries their best to mitigate and as residents age, they develop an unsteady gait and are generally prone to injury from falling. S2 also stated that facility can’t restrain residents or violate their rights, however, facility does take measures to mitigate injuries from falls like bedside mats, assisting with transferring and transitioning, etc. During interviews with residents, all residents stated that they are not aware of any falls or anyone complaining about falling. During interviews with other parties, they stated that they do not wish to disclose the name of the resident or share any other details at this time.

Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

---Facility has insufficient staffing.

It was alleged that there is a lack of staff at facility. To investigate the allegation, on 02/22/2023, LPA conducted a physical plant tour at around 10:00 AM, requested documents at 10:45 AM and interviewed four (04) staff between 10:45 AM to 11:30 AM. On 05/07/2023, LPA interviewed six residents from 11:00 AM – 12:30 PM and other parties from 1:00 – 1:30 PM. During the physical plant tour, LPA observed three (03) care staff in Assisted Living and three (03) care staff in Memory Care. The facility's Personnel Report shows there are at least three (03) care staff on duty during all shifts in Assisted Living providing care for fifty-three (53) residents and at least three (03) care staff on duty during all shifts in Memory Care providing care to twenty-three (23) residents. During interviews with staff, Staff #1 and Staff #3 (S1 and S3) stated facility tries to keep at least three (03) caregivers in Assisted Living along with one (01) MedTech to assist when needed and the same number of caregivers for Memory Care. Staff #2 (S2) stated they need more care staff, and facility is always hiring, but are still able to meet residents’ needs. Staff #3 (S3) also stated that they are all a team and, if needed, administration workers will lend a hand. Staff #4 (S4) stated they do not feel facility is short staffed. During interviews with residents, all residents stated staff respond to their needs timely and feel there are enough care staff available. During interviews with residents, all residents stated staff respond to their needs timely and feel there are enough care staff available.

(CONT. LIC9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20230221085616

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: 05/07/2023

NARRATIVE

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During interviews with other parties, they stated that they do not wish to disclose the name of the resident or share any other details at this time.

Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

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

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2023

LIC9099 (FAS) - (06/04)

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