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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 09/20/2024
Date Signed: 09/20/2024 02:55:09 PM


Document Has Been Signed on 09/20/2024 02:55 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 HILLSFACILITY NUMBER:
197609103
ADMINISTRATOR:VANESSA JEWELLFACILITY TYPE:
740
ADDRESS:1745 N GRAMERCY PLACETELEPHONE:
(323) 467-3121
CITY:LOS ANGELESSTATE: CAZIP CODE:
90028
CAPACITY:120CENSUS: DATE:
09/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Vasessa JewellTIME COMPLETED:
03:00 PM
NARRATIVE
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At 9:00 AM, on 09/20/2024 Licensing Program Analyst, (LPA) Raymond Comer, conducted an subsequent complaint visit for complaint #31-AS-20240724164758. During the course of the investigation, LPA discovered deficiencies in the facility. The deficiencies are addressed on this LIC 809 as part of a case management visit.

In the course of the complaint investigation, LPA observed the licensee's policies and procedures regarding documentation retention state that staff communications, Incident reports, end of shift reports and medication staff communication logs are only kept for ninety (90) days and then subsequently destroyed. Due to the Licensee's records retention policy being in conflict with California Title 22 records retention requirements, a deficiency is cited on an LIC 809-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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Document Has Been Signed on 09/20/2024 02:55 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2024
Section Cited
CCR
87506(e)87506(e)

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87506(e) - RESIDENT RECORDS
Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This represents a potential health and safety issue to residents in care.
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Administrator says they will work with licensee to amend the facility's documentation retention policy to comply with California Title 22 regulations.
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This requirement is not met as evidenced by:
The Licensee's Documentation Retention Policy only allows retention of documents for a minimun of 90 days and then, records are to be subsequently destroyed.
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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: Eva MillerTELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond ComerTELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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