197609103-6-10-2024-31-AS-RCOR-D64HJ3-20240610061341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 06/07/2024
Date Signed: 06/10/2024 06:15:07 AM

Document Has Been Signed on 06/10/2024 06:15 AM - 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:	06/07/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst, (LPA) Raymond Comer, made an unannounced site visit to this facility as a continuation of the Required 1 Year Annual Inspection conducted on 06/06/2024. LPA met with Administrator, Vanessa Jewell and the purpose of visit was disclosed.

The following remaining inspection domains were observed, reviewed and inspected:

Fire Detection/Protection system is present in the facility. Multiple smoke and carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. Fire system back up and tests are done, in house, on a monthly basis. Fire drill last conducted May 15, 2024.

Fire extinguishers were observed throughout the facility on all floors. All extinguishers were last serviced on June 30, 2023. Evacuation chairs were observed in each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility.

Kitchen: LPA observed kitchen as clean, commercial refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons were observed near any food areas.

Medications The medications were locked in the medication carts, properly labeled, and stored. Medication documentation and implementation appeared to be complete. First aid kits were observed on each medication cart stored/parked in the medication room located in the second floor.

[Continued on LIC 809C]

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

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: 06/07/2024

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Laundry: LPA observed the laundry room located on the fourth floor, across from salon. Residents have access to the laundry area to do their own laundry. Laundry area is clean and clear from obstruction. Cleaning supplies and other toxins are stored in separate locked storage area and inaccessible to residents.

Commons: Activity rooms, movie theater, dining rooms, pool hall, exercise room and library observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed.

Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms on all floors were inspected and observed to maintain required furnishing and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 114.5°F. Within the required range.

Outdoor: Courtyard area observed to have a shaded patio, with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility.

Resident records: Resident files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.

Staff records: Staff files were reviewed. Criminal record clearances, Health Screening, Employee Rights Records were present and Staff are associated to this facility. Staff records appear to be complete and current.

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was given to facility Administrator.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024

LIC809 (FAS) - (06/04)

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