197609103-9-20-2024-31-AS-EMIR-DEERF5-20250303115834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:48:09 PM

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
09/16/2024 and conducted by Evaluator Raymond Comer

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240916114553

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: 74	DATE:	09/20/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not assist resident with mobility needs in a timely manner-

INVESTIGATION FINDINGS:

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On Friday, 9/20/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial complaint visit regarding the allegation listed above.

At 9:15 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: Staff did not assist resident with mobility needs in a timely manner-

It was alleged that the right side padding on Resident #1, (R1's) wheelchair was loose, causing leg irritation. R1 requested help from staff to resolve. However, staff was stated as not providing assistance.

[LIC 9099C] Continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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-20240916114553

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: 09/20/2024

NARRATIVE

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To investigate the allegation, LPA conducted interviews with Staff from 10:00am to 11:15am, and interview with R1 from 11:25 to 12:25pm.

LPA's interview with the Administrator revealed the following: On Monday, (9/16/24) R1 informed the Administrator that the leg pad on their wheelchair was very loose, causing it to irritate R1's right leg. The Administrator responded to R1 saying, although staff are not permitted to make any modifications to a resident's medical devices, staff would be sent to assess the problem. On the same day, the Administrator and a staff member, went to R1's room, and adjusted two bolts on R1's wheelchair. Once the adjustment was completed, R1 was stated to have thanked staff for resolving the issue.

LPA's interview with R1 revealed that staff did indeed resolve the issue with their wheelchair, and that the problem was resolved within the same day of R1's request for staff assistance. During the interview, LPA observed R1's wheelchair, and witnessed that the leg pad was attached, and functioning as required. R1 confirmed to LPA that their mobility needs were addressed by staff in a timely manner.

Based on LPA's observations, and interviews,the allegation is UNSUBSTANTIATED at this time.

An Exit interview was conducted, and report was provided to the Administrator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC9099 (FAS) - (06/04)

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