197609103-2-13-2025-31-AS-EMIR-DFKMEU-20250409093316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 02/13/2025
Date Signed: 02/13/2025 01:39:12 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
06/04/2024 and conducted by Evaluator Raymond Comer

COMPLAINT CONTROL NUMBER: 31-AS-20240604154507

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: 68	DATE:	02/13/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Keith Bernanbe		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not prevent resident from sustaining a fracture while in care-
Staff did not seek medical attention in a timely manner-

INVESTIGATION FINDINGS:

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On 9/06/24, Licensing Program Analyst, (LPA) Raymond Comer conducted a subsequent visit to conclude investigation of the above allegation(s). LPA met with the administrator, Vanessa Jewell, advising of the complaint. Initial visit was made on 6/06/24. The complaint was also referred to Investigations Branch (IB) and accepted by Investigator, Veronica Padilla, as a full investigation. IB Padilla’s investigation consisted of interviews with facility, staff, family members of Resident#1 (R1), and review of facility records. IB Padilla also searched text messages submitted by relevant staff, conducted investigations, and reviewed documents received from outside agency/services. The following is a summary of IB’s investigation:
On 06/10/24, IB conducted interviews with family member of R1. Family member believes that R1 sustained an unwitnessed fall from their bed on 10/31/23, between the hours of 1200 and 0600. States that R1 was found on the ground in their room several hours later and that staff failed to report. Staff called saying R1 was in a lot of pain. The Family member asked staff if R1 had fallen, and staff stated, “no”.

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

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-20240604154507

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: 02/13/2025

NARRATIVE

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On 06/12/24, IB obtained the following documents gathered from LPA, Raymond Comer, during the course of his initial investigation: R1’s Plan of Care, Resident Assessment, Physician Report, Release of Resident Medical Information, Staff Narrative Charting, Admissions Agreement and other relevant documents.

On 6/14/24, IB conducted an interview with Hospice personnel Witness#1 (W1) provider of hospice care for R1. W1 submitted an email to IB investigator stating R1 requires maximum assistance with transfers and is a fall risk. W1’s email response contains a statement from R1’s doctor showing that R1 is 100% dependent for all care needs. Communications log submitted by W1 shows, that on 10/31/23, facility staff were aware that R1 was in extreme pain and not physically able to stand, nor move their leg without experiencing a lot of pain, and that Hospice agency was not notified of R1’s fall injury.

On 08/15/24, IB conducted an interview with staff 1 (S1), who confirmed that R1 had sustained a fall from their bed on 10/30/23 around 01:00am. S1 states that on 11/01/23, they inquired to the responsible caregivers about the falling incident. The caregivers responded that they, “…didn’t think it was necessary to report it”. S1 states that disciplinary actions were taken against the responsible caregiver staff for failing to report at the time of the incident’s occurrence.

On 8/19/24, IB conducted a subsequent interview with W1 who spoke with IB investigator, via phone, and stated the following: W1 contacted facility staff and Administrator asking if R1 had fallen; Staff and Administrator, “kept saying no”. W1 stated to IB investigator that protocol requires, “…when a patient falls, the expectation of the facility is to contact hospice immediately. We have to be notified immediately…”.

On 08/20/24, IB conducted an interview with staff 2 (S2), who assisted R1 at the time of the reported incident. S2 confirms that they did not conduct a physical check of R1 for any injuries, stating, “I messed up on that aspect”.

On 8/28/24, IB conducted a records review of relevant documents submitted by Kaiser records department. IB’s review of records reveals, on 11/03/23, R1 was admitted for a left hip fracture due to a fall injury which occurred at the facility. Noted comments indicate R1 sustained a fall on 10/31/23, and was put back to bed with no concerns, and that family was not informed of the injury until the following day.

[continued on LIC9099C]

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240604154507

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: 02/13/2025

NARRATIVE

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On 08/30/24, IB conducted an interview with staff 3 (S3), who stated that, if an injury is suspected, staff are trained to check residents for any bruises, report the incident to their supervisor, and call 911 if there is any pain or bleeding. S3 states that staff did not report the incident, in spite of R1’s constant complaints of pain, saying that R1 always complained of pain, “which was normal behavior for R1”.

On 9/04/24, IB conducted an interview with facility staff 4. (S4) who stated they were not at the facility and the time of the incident involving R1. However, S4 stated concerns of the facility not having enough staff to keep the residents safe.

On 09/09/24, IB conducted an interview with resident 2 (R2), who was present at the time of the incident involving R1. R2 stated they were awakened from the sound of screams coming from R1’s room. R2 went looking for staff to assist R1 because it appeared R1 was in a great deal of pain.

Based on interviews with staff, residents, and review of relevant documents, it appears that facility staff failed to report R1’s suspected falling incident to supervisory staff, nor provide required medical assessment and treatment in a timely manner.

Therefore, pursuant to Title 22, Division 6, Chapter 1, the above allegation(s) are Substantiated. An immediate Civil Penalty of $500.00 is being issued today; Refer to LIC 421M. An additional Civil Penalty determination may be assessed at a later date.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240604154507

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: 02/13/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/28/2025 Section Cited CCR 87466	1 2 3 4 5 6 7	(87466) Observation of the Resident- Licensee shall ensure residents are regularly observed for changes in physical... functioning...appropriate assistance is provided when such observation reveals unmet needs...This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Liencee shall submit evidence of vendored trainings to be provided to staff regarding the observation and medical assessment of residents, in order to prevent injuries while in care. Licensee shall submit afformentioned evidence to CCL no later than 2.28.2025
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted by (IB) investigator, facility staff failed to provide required medical assessment and treatment in a timely manner, which posed an immediate heatlh and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 02/28/2025 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) Incidental Medical and Dental Care: Licensee shall immediately telephone 9-1-1 if an injury...has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Liencee shall submit evidence of vendored trainings to be provided to staff regarding timely reporting of resident injuries/accidents while in care. Licensee shall submit afformentioned evidence to CCL no later than 2.28.2025
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted by (IB) investigator, facility staff failed to provide timely reporting of R1’s falling incident, which poses an immediate heatlh and safety risk to residents in care.	8 9 10 11 12 13 14

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: 02/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025

LIC9099 (FAS) - (06/04)

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