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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 12/29/2021
Date Signed: 12/29/2021 01:13:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: 60DATE:
12/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Gerard PalmosTIME COMPLETED:
01:12 PM
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced case management visit to follow up on a self reporting incident by the facility that occurred on 12/24/2021. LPA contacted the facility at 12:03pm and spoke with Gerard Palmos staff # 1 (S1) the Resident Service Coordinator and explained the purpose of this call. Around 10:00am on 12/24/2021 R1 daughter reported to ED that some ladies were raping him, and that R1 was man handled by an individual throwing him against the wall of the door. Staff conducted a follow up and R1 stated "it never happened and it didn't occur. A body and skin check was conducted on R1, no noted concerns or bruising observed and the skin was overall in tact. At approximately 12:10pm LPA interviewed staff. Although R1 stated it never happened, LPA requested and obtained copies of relevant documents.

LPA conducted a phone interview due to a positive Covid-19 case and facility awaiting testing results that were conducted on 12/25/2021.

Based on documents obtained and interviews, LPA has determined that further investigation is required at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena LacyTELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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