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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 02/20/2025
Date Signed: 02/20/2025 04:03:11 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
02/12/2025 and conducted by Evaluator Raymond Comer
COMPLAINT CONTROL NUMBER: 31-AS-20250212131914
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:
02/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Keith BernanbeTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff spoke inappropriately to resident-
INVESTIGATION FINDINGS:
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Today,Thursday, 2/20/25, at 10:00 am, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannuouned,subsequent complaint visit to continue investigation of 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 2/13/25.

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. From 11:00 am to 1:30 pm, LPA conducted interviews with staff, and Resident#2 (R2) .

[LIC9099C] Continued---
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 4
Control Number 31-AS-20250212131914
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: 02/20/2025
NARRATIVE
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Allegation: Staff spoke inappropriately to resident- The reporting party (RP) alleges that staff-caregiver (S7) yelled at resident#2 (R2). Per RP, R2 was stated to say they no longer want S7 providing them direct care and assistance.
LPA interview with staff-Resident Services Director (S6) revealed the following: R2 spoke to S6, stating that caregiver, S7 acted "unprofessionally", spoke rudely, and handled R2 "roughly" when assisting them with diaper changes. Per S6, S7 was spoken to by their supervisor regarding R2's concerns. S7 received a written warning citing unsatisfactory job performance. Per S6, to honor R2's request, S7 no longer provides R2 direct assistance with bathing/grooming/diaper changes.
LPA interview with staff-caregiver (S7) revealed the following: S7 refutes the claim of "yelling" at R2. However, S7 corroborates that she "could have communicated better" with R2 and states apologizing to R2 regarding the "rough" handling of the resident when assisting with their diaper changes.
LPA interview with resident#2 (R2) revealed the following: R2 stated that S7 did speak inappropriately, communicating rudely, and speaking in a condescending manner. R2 stated to LPA that facility management's response to this concern demonstrates proper respect to their personal rights; Per R2, the issue has been addressed to their satisfaction.

Based on interviews with staff and resident, staff did speak inappropriately to resident. Therefore, the allegation is deemed SUBSTANTIATED at this time.

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

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20250212131914
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: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities-(a) Residents in all residential care facilities...shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff...This requirement is not met as evdenced by:
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Corrected before visit. Licensee has spoken with caregiver, issued disciplinary action to caregiver, and removed caregiver from providing further assistance to resident.
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Based on interviews, facility caregiver spoke inappropriately to Resident#2 (R2), violating their personal rights, which poses a immediate Health, Safety, or Personal Rights risk to clients 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: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4