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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 02/06/2025
Date Signed: 02/06/2025 02:31:11 PM

Substantiated


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
02/04/2025 and conducted by Evaluator Raymond Comer
COMPLAINT CONTROL NUMBER: 31-AS-20250204161800
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: 68DATE:
02/06/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Keith BernanbeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Unqualified staff is providing care and supervision-
INVESTIGATION FINDINGS:
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On Thursday, 2/06/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced, initial10-day complaint visit to investigate the above allegation. LPA met with the Administrator, Keith Bernanbe, presented official CDSS identification, and reason for the visit was disclosed.

At 10:10 am, LPA conducted a physical plant tour; no health and safety issues were observed.

To investigate this allegation, LPA received Facility resident roster, and staff roster. At 10:10 am, LPA conducted a review of Staff1 (S1's) employee file. Between 11:15 am and 12:30 pm, LPA interviewed the Administrator, staff, and three (3) residents.

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

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
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 3
Control Number 31-AS-20250204161800
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: 02/06/2025
NARRATIVE
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Allegation: Unqualified staff is providing care and supervision- The Reporting Party (RP) Alleges that Staff#1 (S1) provides caregiver services to residents in the facilities memory care unit, but is not qualified.

LPA interview with Administrator revealed the following: S1 was initially hired to work as a facility caregiver, but currently functions as a memory care unit activities assistant "programmer". (i.e. creating the resident activities calendar, scheduling/coordination of "senior scenic walks", arts and crafts, stimulation activities, trivia game activities, etc.)

LPA interview with Staff#2 (S2) and Staff#3 (S3) revealed the following: S1's primary role is that of a activities "programmer". In addition, S1 does, at times, help caregiver staff as a "floater" assisting residents, and other caregiver staff when necessary.

LPA interviews which three (3) memory care residents reveals the following: three (3) out of three (3) residents state being familiar with S1 and confirm that S1 has provided satisfactory staff care and assistance.
However, upon review of S1's employee file, and corroborative statements from S2, It was found that S1's previous supervisor (no longer associated with the facility) failed to provide documented proof that S1 completed all "in-service" staff trainings. Thus, this allegation has been substantiated.

Exit interview conducted, and report provided. Deficiencies cited on LIC9099D.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250204161800
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
87411(c)(6)
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Licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). ...Documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.
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Licensee shall submit proof that S1 has re-taken and completed all facility staff "in service" trainings. Additionally, S1's supervisor will verifiy "in-service" re-trainings as completed. Licensee shall submit to CCL no later than 2.14.2025
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This requirement is not met as evidenced by: Based on records review and interviews conducted by LPA, the facility did not provide supervisory verification that all facility "in-service" trainings were completed by S1, which poses 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: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3