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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 02/21/2025
Date Signed: 02/21/2025 11:44:14 AM

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
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:
02/21/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kieth BernanbeTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff physically abused resident-
INVESTIGATION FINDINGS:
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Today,Friday, 2/21/25, at 8:30 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. prior subsequent visit completed on 2/20/25, and initial10- day visit was completed on 2/13/25.

At 8:40 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 9:00 am to 10:30 am, LPA conducted interviews with staff, and residents

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

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
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 2
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: 02/21/2025
NARRATIVE
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Allegation: Staff physically abused resident- The reporting party (RP) alleges that sometime in the month of Jan, 2025, Resident#1 (R1) suffered physical abuse by caregiver staff (S5). Per the RP, when caregiver staff were providing Resident#1 (R1) a diaper change, S5 was alleged to have "strangled and slapped" R1.
LPA interview with the RP revealed the following: RP says she heard about the alleged abuse incident from staff med tech (S1). Per RP, S1 also reported the alleged abuse incident to their immediate supervisor (S4). LPA interviews with S1 and S4 revealed the following: S1 refutes the RP's claim, stating that she did not witness, nor hear of any abuse inflicted upon R1, nor any other facility resident. S4 also refutes the claim that an abuse of R1 was reported by S1, or any other facility staff.
LPA interviewed five (5) staff who provided to care and assistance to R1. Five (5) out of five (5) staff state not witnessing, nor hearing off any abuse by committed upon R1, nor any other facility resident.
LPA interviewed four (4) memory care residents, and three (3) assisted living residents: All residents interviewed by LPA state that staff respect their personal rights and have never witnessed, nor heard of any abuse committed at the facility. LPA could not interview R1 because resident passed away on 1/19/25.
LPA interviewed responsible family member (F1) of R1 which revealed the following: Per F1, Facility staff treated R1 professionally and with respect to their personal rights. From the time of R1's admission as a resident, until R1's passing in Jan 2025, F1 states that R1 never displayed anxiety with staff and was comfortable interacting with facility staff until R1's passing. .

Based on the information obtained, there is insufficient evidence to corroborate the allegation that resident (R1) was physically abused by staff. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2