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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 02/28/2025
Date Signed: 02/28/2025 02:20:05 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
10/30/2024 and conducted by Evaluator Raymond Comer
COMPLAINT CONTROL NUMBER: 31-AS-20241030125453
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: 69DATE:
02/28/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Keith BarnanbeTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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9
Staff do not respond timely to a resident's alerts-
Staff did not provide adequate care and supervision-
INVESTIGATION FINDINGS:
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On Friday, 02/28/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced subsequent complaint visit at the facility investigating the above allegation(s). LPA met with the Administrator Designee, Keith Bernanbe, and the reason for the visit was disclosed.

The Initial investigation to the above allegations was conducted on 11/05/24. At that time, based on the information received, the complaint pertaining to the above allegations was deemed "Unsubstantiated."

On today's subsequent visit, LPA conducted additional interviews with residents which revealed the following:


[LIC 9099C]- Continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
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-20241030125453
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: 02/28/2025
NARRATIVE
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Allegation: Staff do not respond timely to a resident's alerts- It was reported that R1 pressed the service call button and staff did not respond to provide assistance.

LPA Interviews with seven residents (7) revealed the following: six (6) out of seven (7) residents state staff response times to service calls is both timely and acceptable. LPA entered R1's room and activated the service call button; caregiver staff arrived within six minutes of the call button's activation.

Based on the information obtained through LPA observation, and interviews, it cannot be proven that staff fails to respond to resident service calls. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation: Staff dose not provide adequate care and supervision- It was reported that staff do not know how to change resident diapers. RP states that staff "do not know what they are doing".

LPA's Interviews with seven (7) residents revealed the following: seven (7) out of seven (7) residents state staff are professional and provide satisfactory levels of caregiver assistance.

Based on the information obtained through LPA interviews, it cannot be proven that staff fails to provide adequate service to residents in care. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2