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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 09/24/2024
Date Signed: 09/24/2024 02:39:08 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
09/04/2024 and conducted by Evaluator Raymond Comer
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240904112453
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:
09/24/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Vanessa JewellTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff mismanaged resident's medication-
Staff insufficient to meet resident needs-
INVESTIGATION FINDINGS:
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On Tuesday, 9/24/24, at 9:15am, Licensing Program Analyst (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 9/06/24. LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed.

At 9:35 am, A physical plant tour of the facility was conducted by LPA; No health and safety issues were observed.

Allegation: Staff mismanaged resident's medication-

It was alleged that a dosage error was committed within Resident#1's (R1) medications distribution.

[LIC 9099C Continued]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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-20240904112453
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: 09/24/2024
NARRATIVE
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To investigate the allegation, LPA conducted a records review, interviewed two (2) staff, and eight (08) residents between 11:00 AM to 1:15 PM. A review of R1’s medication administration records reveal R1 was indeed provided their medications as prescribed. Further review shows that a dosage notation error was noticed, and corrected. LPA interviews with Staff indicates that Medical Technicians responsible for the error were counseled, and a discussion regarding due diligence took place to ensure accuracy when notating resident medical information. LPA interviews reveal that eight (8) out of eight (8) residents state having no issues, nor concerns with medication distribution services provided to them by Staff.

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

Allegation: Staff insufficient to meet resident needs-

It was alleged that the facility does not have sufficient Staff to provide adequate medication distribution services to residents.

To investigate the allegation, LPA conducted a records review, interviewed two (2) staff, and eight (08) residents between 11:00 AM to 1:15 PM. A review of the facility's work schedule reveals that a minimum of two (2) Medical Technicians are staffed on all shifts to provide adequate coverage for residents. LPA interviews with Staff reveal that medical service coverage is adequately provided to residents, and that additional staff are available to provide coverage, when necessary. LPA interviews reveal that seven (7) out of eight (8) residents confirm medical staff consistently provide services, such as medication management/distribution and that residents have no issues, nor concerns with staffing sufficiency.

Based on LPA's records review, 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: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
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