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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 08/22/2024
Date Signed: 09/26/2024 09:35:32 AM

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
08/16/2024 and conducted by Evaluator Raymond Comer
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240816104401
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: 74DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Vanessa JewellTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility is in disrepair-

INVESTIGATION FINDINGS:
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On Thursday, 8/22/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial complaint visit regarding the allegation listed above.

At 10:45 AM, LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed. A physical plant tour of the facility was conducted. No health and safety issues were observed.

Allegation: Facility is in disrepair-

It was alleged that broken pipes, located on the ceiling above the the underground parking garage, are leaking water, and multiple buckets, placed below the leaks, are overflowing onto the floor. To investigate the allegation, At 11:15 AM, LPA conducted a physical plant tour, interviewed the Adminstrator, and a staff (S1) at around 11:45 AM. During the physical plant tour, LPA observed a section of parking lot flooring wetted by a slow, steady drip of water coming from the ceiling.
[LIC 9099C Continued]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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 5
Control Number 31-AS-20240816104401
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: 08/22/2024
NARRATIVE
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LPA did observe efforts by the facility to mitigate potential health and safety issues, such as the taping off of the area directly below the leak to prohibit accessibility, and sinage posted displaying "Caution-Wet Flooring". LPA did not observe open, or broken piping, nor did LPA observe buckets on the floor left to contain leaking water. During the interview with the Administrator, they stated the leak is a result of excessive water condensation dripping from HVAC pipe conduit. Administrator says this specific leak only occurs during the summer months when the cooling system is used at peak capacity. A document review of an email communication between the Administrator and the facility's contracted HVAC vendor (NCWS Mechanical Service) indicates the vendor was called out to the assess and provide recommended repairs to resolve the issue.

During LPA interview with staff, (S1) They stated excess water is swept into a drain inlet located near the leak at least twice a day, and as needed.

Based on LPA physical inspection, and interviews with Administrator, and Staff, LPA did not observe the facility to be in disrepair. Thus, this allegation is unsubstantiated.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/16/2024 and conducted by Evaluator Raymond Comer
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240816104401

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: 74DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Vanessa JewellTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Personel Requirements are not being met-
INVESTIGATION FINDINGS:
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On Thursday, 8/22/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial complaint visit regarding the allegation listed above.

At 10:45 AM, LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed. A physical plant tour of the facility was conducted. No health and safety issues were observed.

Allegation: Personel Requirements are not being met-

It was alleged that First Aid training is not being provided annually to Staff. To investigate the allegation, At 11:15 AM, LPA conducted a physical plant tour, interviewed the Adminstrator, and a staff (S2) at around 12:20 PM.

[LIC 9099C-continued]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20240816104401
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: 08/22/2024
NARRATIVE
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During LPA interview with the Administrator, they confirmed that annual First Aid training had not yet been completed for Staff, and that scheduling efforts were in progress. LPA interview with Staff (S2) also confirmed that training had not been completed. S2 provided a list of Staff with status of First Aid training as "pending", and an email communication with Vendor (ON SITE CPR) showing coordination of preliminary scheduling efforts..

Based on the information obtained, this allegation is deemed Substantiated.

An Exit interiew was conducted, a copy of the report was provided, and Appeal Rights explained. Deficiency cited on LIC 9099 D.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240816104401
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2024
Section Cited
CCR
87411(c)(1)
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First aid training not completed for facility staff. 87411(c)(1) Personnel Requirements-General. Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
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Licensee says First aid certification training shall be completed by 9/15/24, with documentation submitted to Licensing.
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Based on interviews, facility staff have not completed annual first aid training which poses a potential health and safety risk to clients 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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5