197609103-3-10-2025-31-AS-EMIR-DEYV47-20250321160550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 03/10/2025
Date Signed: 03/10/2025 02:05:31 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
02/10/2025 and conducted by Evaluator Raymond Comer

COMPLAINT CONTROL NUMBER: 31-AS-20250210120851

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:	03/10/2025
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Keith Bernanbe		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Faciity failed to report suspected abuse/neglect of residents in care-

INVESTIGATION FINDINGS:

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Today, Monday, 3/10/25, at 8:45 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 on 2/14/25.

At 9:00 am, LPA conducted a physical plant tour; no health and safety issues were observed.

Allegation: Reporting Party (RP) alleges, on 11/16/24, a staff (S1), held and pushed a pillow over the face of Resident#1 (R1). RP alleges this incident was reported to Staff Supervisor(s) (S2), and (S3). However, RP alleges that both supervisors ignored the reported incident.

[LIC9099C] Continued---

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

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-20250210120851

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: 03/10/2025

NARRATIVE

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Additionally, RP alleges that Resident#2 (R2) was observed as "covered in urine and feces" lying on the floor in their facility bedroom. RP alleges the facility's night shift staff are responsible for neglect of R2.

To investigate this allegation, LPA received facility resident roster, and staff roster. LPA conducted a review of resident files for R1 and R2, and interviewed facility residents and staff.

Regarding the alleged incident involving R1, LPA interviews with Staff revealed the following: Staff Supervisors (S2 and S3) refute the claim, stating that the alleged incident was never reported to them. Furthermore, both S2 and S3 deny the occurrence of the alleged incident, stating that staff respect R1's personal rights, and provide R1, and all other residents, professional care and supervision. LPA interviews with five (5) Memory Care Unit (MCU) Staff revealed the following: Five (5) out of five (5) staff could not corroborate the allegation, stating they have not witnessed, nor heard of any neglect/abuse committed upon residents by staff. LPA's interview with R1's Responsible Family Member (F1) revealed the following: F1 states, "Our family visits R1 "a minimum of once, or twice per week", and asserts "facility staff respect R1's personal rights, and overall, we are happy staff treatment of R1". F1 states having no facility health or safety concerns.
Regarding the alleged incident involving R2, Staff Supervisors (S2 and S3) refute the allegation, stating that R2 was "well cared for" by staff throughout their residency at the facility. Responsible Family Members were informed, and an incident report was submitted to Community Care Licensing (CCL) regarding R2's fall injury and subsequent ambulance transport to Kaiser for medical evaluation. However, S2 and S3 deny that R2 was "covered in urine and feces" as alleged.
LPA interviews with five (5) Memory Care Unit (MCU) Staffers revealed the following: Five (5) out of five (5) staff could not corroborate the allegation, stating they did not witness, nor hear of any neglect\abuse committed upon R2 by staff.
LPA interview with seven residents revealed the following: Seven (7) out of seven (7) residents state that staff provide adequate levels of care and assistance. All residents interviewed expressed having no concerns regarding neglect, nor abuse of residents by staff.

Based on the information obtained, there was insufficient evidence to prove that staff failed to report suspected abuse/neglect of residents in care. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and a copy of this report delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

LIC9099 (FAS) - (06/04)

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