197609103-12-6-2024-31-AS-EMIR-DEEVMF-20250303153327

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 12/06/2024
Date Signed: 12/06/2024 02:40:51 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
09/30/2024 and conducted by Evaluator Raymond Comer

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240930160917

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:	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff do not ensure that resident's incontinence needs are met-
Staff do not provide resident with laundry service-
Staff do not distribute resident's medication as prescribed-

INVESTIGATION FINDINGS:

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On Friday, 12/06/24, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct a subsequent visit regarding the allegation(s) listed above. LPA conducted the initial complaint visit on 10/03/24. LPA met with facility Administrator, Vanessa Jewell, and the purpose of the visit was disclosed.

At 9:35 am, A physical plant tour of the facility was conducted by LPA; No health and safety issues were observed.

Allegation: Staff do not ensure that resident's incontinence needs are met- It was alleged that staff are inconsistant reguarding provision of incontinence service/diaper changes for Resident#1. (R1)

[LIC 809-C Continued]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240930160917

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: 12/06/2024

NARRATIVE

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To investigate the allegation, LPA conducted records review from 9:35 am to 10:15 am, interview with staff from 10:40 am to 11:25 am, and interview with Residents from 12:00pm to 1:30 pm.

LPA review of resident records revealed that Resident#1 (R1) is identified with having incontinence issues as stated in the Physician's Report. Resident assessment documents show R1 requested staff to provide status checks at least twice per shift. Additionally, resident records indicate that R1 was provided incontinence supplies by the facility at no charge. LPA interviews with R1 revealed the following: R1 confirmed to LPA that staff do provide diaper changes regularly, and as needed. However, expressed frustration that staff's response time was unreasonable when call button is activated. Interviewed Residents (R2 through R5) revealed that staff do provide incontinence services regularly, and as needed in a timely manner. Staff state that R1 is provided incontinence services regularly, and as needed. Staff state R1 often becomes impatient and angry if staff do not show up immediately to answer R1's call button.

Based on LPA records review, interviews with Staff and Residents, the allegation is UNSUBSTANTIATED at this time.

Allegation: Staff do not provide resident with laundry service- It was alleged that staff are not laundering Resident#1 (R1's) clothing and and linens due to R1's refusal to pay an extra $100.00 per month for laundry service.

To investigate the allegation, LPA conducted records review from 9:35 am to 10:15 am, interview with staff from 10:40 am to 11:25 am, and interview with Residents from 12:00pm to 1:30 pm.

LPA review of resident records revealed that Resident#1 (R1) was not charged for laundry service. Interview with Administrator revealed the following: Administrator confirms that charges for laundry services were waived on behalf of R1, and that laundry service was consistently provided to R1 once per week, and at times, twice per week, in response to R1's incontinence service needs.

[LIC 809-C Continued]

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240930160917

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: 12/06/2024

NARRATIVE

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LPA interview with R1 revealed the following: R1 confirmed to LPA that staff do provide them laundry service on a weekly basis. However, expressed frustration that staff, "should clean my things every day", due to them having incontinence issues. Interviewed Residents (R2 through R5) revealed that staff do provide weekly laundry services on a consistent basis.

Based on LPA records review, interviews with Staff and Residents, the allegation is UNSUBSTANTIATED at this time.

Allegation: Staff do not distribute resident's medication as prescribed- It was alleged that staff are not providing Resident#1 (R1) their morning medications at 8:00 am, as prescribed. Instead, distributing R1's medications between 8:00am, and 12:00 pm.

To investigate the allegation, LPA conducted records review from 9:35 am to 10:15 am, interview with staff from 10:40 am to 11:25 am, and interview with Residents from 12:00pm to 1:30 pm.

LPA review of R1's Medication Administration Records (MAR) revealed that Resident#1 (R1) is provided their medications, as prescribed. LPA observed the following: A Staff medical technician attempted to provide R1 their morning medications. However, R1 refused, telling the med tech to leave it in the room for R1 to take at a time of their choosing. The med tech informed R1 that they had to witness R1 take their morning medication, as prescribed. Again, R1 refused to take their morning medication. LPA interview with Residents (R2 through R5) revealing the following: Interviewed Residents state that staff do provide them their medications throughout the day, as prescribed. LPA interviews with Staff revealed the following: Staff state that R1 is often difficult while assisting them with their medications at the times prescribed.

Based on LPA records review, observation, interviews with Staff and Residents, the allegation is UNSUBSTANTIATED at this time.

An Exit interview was conducted, and report was provided to the Administrator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

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