197609103-4-17-2024-31-AS-EMIR-D5ANS7-20240515104236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 04/16/2024
Date Signed: 04/17/2024 08:14:18 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
04/09/2024 and conducted by Evaluator Raymond Comer

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240409144225

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:	DATE:	04/16/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	VANESSA JEWELL		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not assisting resident with incontinence needs
Staff did not respond to resident's call button in a timely manner
Staff do not allow resident to manage own medication

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPAs), Raymond Comer and Micheal Cava conducted an unannounced complaint visit to investigate the above stated allegations. LPA met with the Executive Director Vanessa Jewell and explained the reason for the visit.

Allegation: Staff do not allow resident to manage own medications

It was alleged that R1is restricted from self administering their medications and storing them in their room.
R1 states that, prior to this complaint, they were able to self-administer medications and keep them in their room. Facility Policy states that residents may keep their own medications, if they are kept in a secure enviorment, and that medications are not left sitting out in a resident's room.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

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 2

Control Number 31-AS-20240409144225

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: 04/16/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

However, LPAs interviewed S1 who states R1 kept their medications exposed in open bins on top of their kitchen counter and often keeps door (room #5013) open, allowing other residents access.
LPAs conducted a desk review and observed the following: R1's Physician's report states that they cannot manage their own medications. R1's service plan states the Medication Assistance are to be totally assisted by the Facility's Med Tech. PCP communication, dated 4/5/24, states that R1 "Is unable to utilize arm for safe management of of medication along with a safety concern to keep all meds in a central location locked in a cabinet or have his room door locked" and confirms that "Staff continue to manage meds on hand."

Allegation: Staff are not assisting resident with incontinence needs\Staff did not respond to resident's call button in a timely manner.

It was alleged that R1was not responded to in a timely manner to address incontinence needs, nor provide timely response to R1's activation of call button for Staff assistance.
LPAs conducted an interview with R1 requesting them to activate intercom call button. Response time to R1 service call was nine (9) minutes. LPAs interviewed a total of seven residents (including R1) asking them about the timeliness of service call response by facility staff. All residents interviews stated that Facility Staff responded in a timely manner to service calls.

Based on observations, document review, and resident interviews, the above allegation(s) deemed Unsubstantiated at this time. Exit interview conducted and a copy of this report delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2