197609103-10-29-2024-31-AS-EMIR-DB6UUC-20241119145317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:43:14 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
08/22/2023 and conducted by Evaluator Raymond Comer

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230822143552

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: 67	DATE:	10/29/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident sustained multiple unexplained bruises while in care-
Staff did not safeguard resident’s personal belongings-

INVESTIGATION FINDINGS:

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Today, Tuesday, 10/29/24, at 10:00 am, 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 9/20/24, and subsequent visit on 10/01/24. Today, LPA met with facility Administrator, Vanessa Jewell, and purpose of the visit was disclosed.

At 10:10 am, LPA conducted a physical plant tour of the facility; No health and safety issues were observed.

Allegation: Resident sustained multiple unexplained bruises while in care- It was alleged that Resident#1 (R1) showed bruising on both arms, and staff cannot explain. To investigate the allegation. LPA conducted a records review, and interviews with staff.

[LIC 9099C Continued]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

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-20230822143552

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: 10/29/2024

NARRATIVE

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At 10:30 am, LPA conducted a review of R1's resident files which revealed the following: Staff observations identified R1's general skin condition as "thin and fragile" and to be "monitored in order for skin integrity be maintained." Interviews with Staff corroborate documented observations, and that some of R1's prescribed medications can cause bruising with very little pressure applied to the skin.
Records show that Officers of the Los Angeles Police Department (LAPD) conducted a health "well check" of R1 at the request of the reporting party. A review of LAPD notes show Officers describing R1's condition as "good" and no suspicious injuries were observed.

At 11:00 am, LPA spoke with an outside vendor providing R1 with hospice services. The hospice staffer stated that R1 would sustain bruises from simply being lifted from their bed to the bathroom. Furthermore, staff states that R1 would, at times, exhibit behaviors that could potentially cause bruising.

Based on the information obtained through documents review, and interviews, this allegation is deemed UNSUBSTANTIATED at this time.

Allegation: Staff did not safeguard resident’s personal belongings- It was reported that R1 always wore their wedding ring, however, it was reporting as missing. The reporting party states not knowing the specific time of the ring's disappearance.

To investigate this complaint, LPA conducted a records review, and interviews with administrator. A review of R1's inventory list, signed by R1's Power of Attorney, (POA) notes that the responsible party chose not to fill out the form, and that "all items of value will be left at home." Documents reviewed do not indicate responsible party communicated this issue to Staff. R1 is no longer a resident of the facility, and LPA's attempt to contact the responsible party yielded no response.

Based on the information obtained, it could not be proven that Staff did not safeguard resident's personal belongings. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

An exit interview was conducted, and a copy of this report was proved to the Administrator.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024

LIC9099 (FAS) - (06/04)

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