197609103-2-18-2025-31-AS-EMIR-DERPW4-20250314114004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 02/18/2025
Date Signed: 02/18/2025 02:53:13 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
01/16/2025 and conducted by Evaluator Raymond Comer

COMPLAINT CONTROL NUMBER: 31-AS-20250116121515

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:	02/18/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Keith Bernanbe		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not prevent a resident from eloping while in care-

INVESTIGATION FINDINGS:

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Today,Tuesday, 2/18/25, at 9:35 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned,subsequent complaint visit to continue investigating the above allegation. LPA met with Administrator designee, Keith Bernanbe, presented official CDSS badge identification, and reason for the visit was disclosed. An initial10- day visit was completed by LPA on 1/21/25.

At 9:45 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 10:15 am, LPA conducted a review of Resident 1's (R1's) file, From 11:05 am to 1:00 pm, LPA conducted interviews with facility staff, and R1's responsible family member (F1).

[LIC9099C] Continued---

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

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-20250116121515

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: 02/18/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/18/2025 Section Cited CCR 87464(f)(c)	1 2 3 4 5 6 7	87464(f)(c)- "Care and supervision" means facility assumes responsibility for...assistance with activities of daily living without which the resident’s...safety, or welfare would be endangered. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator shall review regulations regarding supervision and dementia care. Administrator shall provide trainings to staff and submit plans to ensure residents do not elope by POC date of 2/28/25. Plan will be submitted either via fax or email to LPA.
	8 9 10 11 12 13 14	Staff interviews and record review by LPA finds R1, a resident diagnosed as having dementia, and documented instances of wandering from the faciltiy, was able to elope from the facility unsupervised. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250116121515

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: 02/18/2025

NARRATIVE

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Allegation: Staff did not prevent a resident from eloping while in care- The Reporting Party (RP) alleges that on 1/11/25, approx. time of 7:49 pm, Resident#1 (R1) was identified as wandering around the Griffith Park area unattended.

To investigate this allegation, LPA conducted a records review, which revealed the following: Physician's report lists R1 as having a diagnosis of dementia. Incident reports show that, on Saturday, 1/11/25, R1 was last seen at the facility around 5:30 pm. Incident report states that R1 was later found wondering around the Griffith Park area by Los Angeles Police Department Officers who then transport R1 to Kaiser Hospital-Los Angeles for medical evaluation. Records review also revealed that, the following week, a subsequent elopement incident involving R1 occurred on Friday, 1/17/25. On both occasions, R1 was returned to the facility, and responsible family member (F1) was notified. Both incident reports state that R1 did not sustain any injuries, nor discomfort during these elopement events.
LPA conducted interviews with staff which revealed the following: Staff-Resident Services Director, (S1) and Staff-Memory Care Director, (S2) both confirm that R1 eloped from the facility unsupervised, stating that R1 eluded facility's supervision.
LPA interviewed R1's responsible family member (F1) which revealed the following: F1 states that the facility's community is good, and that staff workers "do a good job" of caring for R1. F1 confirms that facility staff provided them immediate notice when R1 eloped from the facility. Upon R1's return to the facility, F1 states the Administrator informed them that staff would be re-trained regarding resident supervision.

Based on LPA records review, and interviews, the allegation that resident wandered away due to lack of supervision, is deemed Substantiated. Exit interview, copy of report, appeal rights, and citation provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

LIC9099 (FAS) - (06/04)

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