197609103-3-11-2025-31-AS-EMIR-DERPW3-20250314114004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 03/11/2025
Date Signed: 03/11/2025 02:33:48 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: 67	DATE:	03/11/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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On Tuesday, 03/11/25, Licensing Program Analyst, (LPA) Raymond Comer, conducted an unannounced subsequent complaint visit at the facility investigating the above allegation. LPA met with the Administrator and reason for the visit was disclosed.

The Initial investigation to the above allegation was conducted on 1/21/25, and subsequent visit conducted on 2/18/25. Based on the information received, the complaint pertaining to the above allegation was deemed as "Substantiated."

On today's subsequent visit, LPA conducted a review of documents and interview of staff which revealed the following:

[LIC 9099C]- Continued

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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
	VISIT DATE: 03/11/2025

NARRATIVE

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

To investigate this allegation, LPA conducted a interviews with staff, which revealed the following: Both Administrator and Staff Director (S1) state that, is spite of R1's dementia diagnosis, the facility's initial pre-placement assessment indicated R1 was on a the "high functioning" end of the dementia spectrum. This resulted in the facility placing R1 as an Assisted Living (AL) resident, with frequent observation and reassessment to determine if AL is the optimal placement. (Per 6/7/24 Needs and Services Plan documentation)
Per the Administrator, from R1's initial placement, R1 was placed on a list of AL residents, "who cannot leave the facility unassisted". The aforementioned list is given to staff during shift meetings and are instructed to provide enhanced vigilance regarding the supervision and frequent well checks of these residents.

Per the Administrator, the facility currently does not have surveillance cameras to visually monitor common areas and perimeter entry/exit points. However, after R1's elopement, the installation of such cameras and the use of fobs tracking resident's distance from the facility's perimeter is being considered in the licensee's strategy to mitigate the occurrence of resident elopement.

LPA review of R1's file and other relevant documents reveals the following: Regarding R1's mental condition, pre-placement appraisal documentation simply states "withdrawn"; omitting PCP's diagnosis. Additionally, staff assessment identifies R1 as "Independent". Thus, needed no redirection, interventions, or room visits.

Therefore:Based on information obtained through documents review and interviews, sufficient evidence was found to sustain the above allegation as Substantiated.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

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