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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 11/05/2024
Date Signed: 11/05/2024 03:06:27 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
10/30/2024 and conducted by Evaluator Raymond Comer
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20241030125453
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: 70DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Vanesssa JewellTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff do not respond timely to a resident's alerts-

Staff did not provide adequate care and supervision-
INVESTIGATION FINDINGS:
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On Tuesday, 11/05/24, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced initial 10-day complaint visit at the facility investigating the above allegation(s). LPA met with the Administrator, Vanessa Jewell, and the reason for the visit was disclosed.

At 09:55 am, LPA conducted a physical plant tour; no health and safety issues were observed.

To investigate the allegation(s), LPA received Facility resident roster, and staff roster. At 10:10 am, LPA conducted a review of Resident 1's (R1) file, and other documents relevant to the investigation. Between 10:45 am and 12:30 pm, LPA interviewed the Administrator, three (3) Staff, three (3) Residents, and R1's Responsible Family Member (F1), via cellphone.

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

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
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-20241030125453
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: 11/05/2024
NARRATIVE
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Allegation: Staff do not respond timely to a resident's alerts- It was reported that during the night of October 29th, 2024, R1 pressed the service call button and staff did not respond to provide assistance.

LPA's review of the facility's service call log reveals that R1's activated service call button was indeed responded to, on multiple occasions, by night staff. Interviews with three (3) residents that are wheelchair bound, and require similar levels of caregiver assistance, revealed the following: three (3) out of three (3) residents state staff response times to service calls is both timely and acceptable. Interviews with three (3) staff, and R1's responsible family member (F1) state that R1, at times, refuses assistance from newly hired staff and/or staff which R1 is unfamiliar. LPA entered R1's room and activated the service call button; caregiver staff arrived within three minutes of the call button's activation.

Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff fails to respond to resident service calls. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation: Staff did not provide adequate care and supervision

LPA's Interviews with three (3) residents that are wheelchair bound, and require similar levels of caregiver assistance, revealed the following: three (3) out of three (3) residents state staff are professional and do provide adequate levels of caregiver assistance. Interviews with three (3) staff, and R1's responsible family member (F1) reveal that R1, at times, refuses assistance from newly hired staff and/or staff which R1 is unfamiliar. LPA interview and the Administrator reveals that, although there have been challenges with staff turnover, the facility has added an additional caregiver staff to its memory care unit in order to maintain adequate levels of service coverage.

Based on the information obtained through LPA observation, records review, and interviews, it cannot be proven that staff fails to respond to resident service calls. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2