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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 11/15/2021
Date Signed: 11/15/2021 03:40:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 51DATE:
11/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Vanessa JewellTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced case management visit to follow up on an incident that occurred on 9/11/21 around 4pm, R1 was found next to the Gelato ice cream shop located at Hollywood and Wilton. R1 was found and returned by Jana Mahany the Community Relation Director, no injuries were noted upon return. At 11:45am LPA requested and obtained copies of relevant documents and facility records. At 1:10pm LPA began interviews with the Executive Director Vanessa Jewell and Resident Service Director Keith Bernabe.

Based on documents obtained LPA has determined that further investigation is required at this time.

There is no immediate Health and Safety issues noted during this visit.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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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