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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 12/12/2024
Date Signed: 12/20/2024 01:32:30 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.ASC, 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
09/28/2023 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230928100059
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: 72DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Vanessa JewellTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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1. Staff do not provide a planned activities program for residents
2. Staff do not provide hydration to residents between meals
3. Staff do not ensure residents' right to wear their own clothes is met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tuesday Cabiness and Licensing Program Manager (LPM) Troy Agard conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. LPA and LPM met with Administrator, Vanessa Jewell and informed her the reason of the visit. An initial visit was conducted on 10/05/2023. During today's visit, from 945am to 230pm, LPA and LPM, conducted interviews, reviewed facility and resident documents, and conducted a physical plant inspection. The following was determined:

Regarding the allegation #1: Staff do not provide a planned activities program for residents. It’s being alleged that residents are neglected all day and sit there with no type of activities throughout the day. During interviews with residents and staff it was confirm that residents are provided with activities such as yoga, bingo, walking groups, a book club and drama club, etc for residents in assisted living and memory care. Activities are tailored based on residents’ cognitive abilities. Based on interviews and documents reviewed this allegation is Unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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 5
Control Number 31-AS-20230928100059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS
FACILITY NUMBER: 197609103
VISIT DATE: 12/12/2024
NARRATIVE
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Regarding the allegation #2: Staff do not provide hydration to residents between meals. It’s being alleged residents are not offered hydration in between meals. During interviews with residents and staff it was determined that residents have access to pitchers of water and water stations with infused fruits. During facility tour LPA & LPM observed water stations throughout the facility, including the Bistro. Furthermore, it was determined residents are provided with hydration during breakfast, lunch, dinner, and at snack times. Residents can also request for coffee, juice, and tea at any time. Based on interviews and observations this allegation is Unsubstantiated this time.

Regarding the allegation #3: Staff do not ensure residents' right to wear their own clothes is met. It’s being alleged residents do not have clean clothes and caregivers have to borrow from other residents. During interviews with residents and staff it was determined that residents clothing are washed on a weekly basis. Residents in the memory care unit are provided with free (included in their monthly rent) laundry services performed by the evening and night shift staff. Residents in the assisted living are responsible for their own laundry needs. Based on interviews, this allegation is Unsubstantiated at this time.

Exit interview and copy of report provided.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
09/28/2023 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230928100059

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: 72DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Vanessa JewellTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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2
3
4
5
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7
8
9
Staff do not provide assistance as needed to residents during overnight shift
INVESTIGATION FINDINGS:
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2
3
4
5
6
7
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9
10
11
12
13
Licensing Program Analyst (LPA) Tuesday Cabiness and Licensing Program Manager (LPM) Troy Agard conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. LPA and LPM met with Administrator, Vanessa Jewell and informed her the reason of the visit. An initial visit was conducted on 10/05/2023. During today's visit, from 945am to 3pm, LPA and LPM, conducted interviews, reviewed facility and resident documents, and conducted a physical plant inspection. The following was determined:

Regarding the allegation: Staff do not provide assistance as needed to residents during overnight shift. It’s being alleged team members that work NOC (night) shift do not do their 2-hour rounds to check on soiled residents. During interviews with residents and staff it was determined that rounds during the night shift are not being made consistently. Based on a review of the facility schedule there are inconsistencies with coverage in staffing for the night shift. Which may result in residents being left soiled or unchecked during the night in the assisted living and/or memory care units. Therefore, based on interviews, and documentation
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20230928100059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACIFICA SENIOR LIVING HOLLYWOOD HILLS
FACILITY NUMBER: 197609103
VISIT DATE: 12/12/2024
NARRATIVE
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the allegation is Substantiated at this time.

Exit interview, citation, appeal rights and copy of report provided to Administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20230928100059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 12/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2025
Section Cited
CCR
87705(c)(4)
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Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety...
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Executive Director will in-service with managment regarding staff coverage. And moving forward, the staff schedule will reflect additional names, with staff or manager who are working and covering shifts that are vacant.
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This requirement was not met, evidenced by, based on interviews and documentation, during the night shift there are inconsistencies with coverage in staffing. This poses as a potential 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5