197609103-6-6-2024-31-AS-RCOR-D5YVNS-20240606163538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 06/06/2024
Date Signed: 06/06/2024 04:35:42 PM

Document Has Been Signed on 06/06/2024 04:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 72	DATE:	06/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	04:45 PM

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On 06/06/24, 9:45 AM Licensing Program Analyst (LPA) Raymond Comer conducted an unannounced Annual required visit and inspection of the Facility, met with Administrator, Vanessa Jewell, and reason for the visit was stated.

Facility is licensed as a complex occupying six (6) floors and a penthouse. Fire clearance approved for (110) non-ambulatory, and an additional ten (10) bedridden. Hospice waiver approved for fifteen (15) residents. At the time of this inspection, there are six (6) residents receiving hospice care services, and two (2) bedridden residents.

At 10:05AM, LPA conducted a tour of the physical plant with the Administrator and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main doors is the primary entry/exit access. Screening area is located immediately upon entrance. As the Facility provides dementia care, LPA observed the delayed egress system working properly.
Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Covid 19 prevention protocols are posted. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 78.0°F. within the required range.
The facility maintains an approved Mitigation and Infection Control Plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 5/15/2024.

[Continued on LIC 809-C]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/06/2024

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Resident records: A total of seven (7) Resident files were reviewed for current IPP and/or needs and services plans, physician report, admission agreements, pre-admission appraisals\reappraisals, centrally stored medication logs, and resident identification. Resident records appeared to be complete and current.

Due to time constraints, LPA was unable to complete the required Annual inspection visit. LPA will complete at a later date.

Exit interview conducted/Copy of report given to Administrator, Vanessa Jewell.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024

LIC809 (FAS) - (06/04)

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