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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 01/03/2024
Date Signed: 05/30/2024 12:08:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/02/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20240102131717
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: 76DATE:
01/03/2024
UNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Jana MahanyTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility did not prevent resident from developing a stage 4 pressure injury while in care.
Facility did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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This report was amended to add additional information received after delivering an initial visit report on 01/03/2024. Executive Director, Venessa Jewell will be signing and accepting the AMENDED report.
On 01/03/2024, Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA met with Marketing Director, Jana Mahany, and explained the reason for the visit. LPA spoke with the Executive Director, Venessa Jewell, and designated Mahany to sign and accept this report.
--- Due to improper care, resident developed prohibited health condition.
It was alleged that while at the hospital, Resident #1 (R1) was observed to have three bed sores located on the left hip (unstageable or stage 4), left ankle and left knee. To investigate this allegation, on 01/03/2024, LPA requested documents at 12:30PM, interviewed three staff from 12:45PM–2:15PM and interviewed other parties at 2:30PM. Staff #1(S1) and Staff #3(S3) verified R1 developed pressure injury on left hip and right lower leg on 12/14/23. They notified R1’s responsible party(RP) and suggested an initiation of hospice services. RP refused and chose Home Health(HH) services for R1's pressure injuries.(cont. on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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 4
Control Number 31-AS-20240102131717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS
FACILITY NUMBER: 197609103
VISIT DATE: 01/03/2024
NARRATIVE
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HH started to provide wound care as of 12/18/23. However, the conditions of the wounds were not improving. During interviews with medical professionals, on 12/27/23, R1 was admitted to the emergency department (ED) at which time in addition to other health complications, R1 was presented with multiple pressure injuries, including Unstageable pressure injury on left hip. A review of the facility’s documents including the documentation completed by the HH care agency indicates that on 12/14/2023, R1 was noted with a small sore on the left thigh and redness on the right lower leg. The conditions of the injuries were not improving and R1 began receiving HH care assistance for pressure injuries on 12/18/2023. Between 12/18/23 and 12/27/23, R1’s pressure injuries were not getting better. On 12/27/24 due to health complication R1 was sent to the hospital and was presented with Unstageable and stage 3-4 pressure injuries. A review of hospital medical records received on 05/17/24 revealed that at the time of R1’s admission to the ED, R1 presented with multiple pressure injuries. A pressure injury on the left hip was staged as Unstageable and others were staged Stage 3 and 4. Based on interviews and record review, there is a sufficient information to verify that while in care of the facility, R1 developed prohibited health condition. Facility did not seek proper care and supervision and/or required incidental medical services. Therefore, the allegation is SUBSTANTIATED at this time.
---Facility did not seek medical attention in a timely manner.
It was alleged that R1’s health was declining, and facility did not seek required medical attention or call 911 immediately. To investigate this allegation, on 01/03/2024, LPA requested documents at around 12:30 PM, interviewed three (03) staff from 12:45 PM – 2:15 PM and interviewed other parties at 2:30 PM. Interviews of facility staff and other medical professionals revealed that since beginning of December 2023, facility staff had noticed significant changes in R1’s physical and mental condition, however, no additional steps were taken by facility staff to seek proper medical attention until 12/27/23. On 12/27/23, R1 was transferred to the hospital after facility staff received a phone call from a medical professional, who was contacted by R1’s family member, and requested to transfer R1 to the hospital due to health decline. A review of facility documents and an incident report submitted to the Department, verified the information revealed from interviews during the investigation. Overall investigation revealed that although facility staff noted significant changes in R1’s health condition, including developing prohibited health condition, they did not seek required medical attention or attempt to seek a higher level of care in timely manner. Therefore, based on interviews and record review, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview was conducted and a copy of report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20240102131717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS
FACILITY NUMBER: 197609103
VISIT DATE: 01/03/2024
NARRATIVE
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SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20240102131717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS
FACILITY NUMBER: 197609103
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2024
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be ...retained in a residential care facility for the elderly:(1)Stage 3 and 4 pressure injuries.
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The Administrator will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to 87615 Prohibited Health Conditions; The Administrator will also submit proof of training for all staff. All proof must be sent to the LPA by the POC due date.
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This requirement is not met as evidenced by; Based on record review and interviews, the facility retained in a resident with Stage 4 and unstageable pressure injuries which poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
01/05/2024
Section Cited
CCR
87468.1(a)(16)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have the following personal rights (16) To received medical care or other services. This requirement was not met as evidenced by:
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The Administrator will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to 87468.1 Personal Rights of Residents in All Facilities; The POC must be sent to the LPA by the POC due date.
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Based on record review and interviews, the facility did not allow an ambulance to take R1 to the hospital immediately and receive medical care. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4