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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 09/18/2025
Date Signed: 09/18/2025 03:33:03 PM

Document Has Been Signed on 09/18/2025 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HOLLYWOOD HILLS SENIOR LIVINGFACILITY NUMBER:
197609103
ADMINISTRATOR/
DIRECTOR:		VANESSA JEWELLFACILITY TYPE:
740
ADDRESS:1745 N GRAMERCY PLACETELEPHONE:
(323) 467-3121
CITY:LOS ANGELESSTATE: CAZIP CODE:
90028
CAPACITY: 120CENSUS: 67DATE:
09/18/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:07 AM
MET WITH:Vanessa Jewell- Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst, (LPA) Ray Comer, made an unannounced site visit to this facility as a continuation of the required annual Inspection initially conducted on 09/12/2025. LPA met with Administrator and the purpose of visit was disclosed.

The following remaining inspection domains were observed, reviewed and inspected:

Fire Detection/Protection system is present in the facility. Multiple smoke and carbon monoxide alarms are installed, hardwired, and interconnected throughout the Facility. LPA observed all fire suppression and signaling systems to be tested and "passed" inspection by contracted vendor, Fire Alliance Inc. Inspection report submitted to Los Angeles Fire Department on 01/22/2025. Fire drill last conducted September 10, 2025. Fire extinguishers were observed throughout the facility on all floors. All extinguishers were last serviced by July 2, 2025. Evacuation chairs were observed in each stairwell. Roof access is inaccessible to residents. Evacuation routes are clearly labelled and posted throughout the facility.
Kitchen: LPA observed kitchen as clean, refrigerators and freezers observed to maintain required temperatures, appliances and fixtures functional, and a sufficient amount of perishable and non-perishable food observed as properly stored and labeled. Residents do not have access to the kitchen; knives and sharps are properly stored and inaccessible to residents. Facility menu appears to meet the daily dietary needs of the residents. No pesticides, nor poisons were observed near any food areas. However, LPA observed two (2) staff working in kitchen area without required hair net coverings. Deficiency will be issued in LIC 809-D.

[continued on LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: HOLLYWOOD HILLS SENIOR LIVING
FACILITY NUMBER: 197609103
VISIT DATE: 09/18/2025
NARRATIVE
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Commons: Activity rooms, movie theater, dining rooms, pool hall, exercise room, and library observed to be clean with adequate seating for residents. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed by LPA.

Medications: Medication room is located on first floor. LPA observed room as locked and inaccessible to residents. Inside the room, medications are properly labeled and stored in secured cabinets. Resident medication documentation and distribution records appear to be accurate and complete. However, an adjacent door to room where refrigerated medications are stored was observed as unlocked and accessible. Deficiency will be issued in LIC 809-D.

Laundry: LPA observed the laundry room located on the sub-floor, and forth floor, across from salon. Residents have access to the fourth floor laundry area to do their own laundry. Sub floor laundry area is serviced by staff-only and inaccessible to residents. All laundry areas are clean and clear from obstruction. Cleaning supplies and other toxins are stored in separate locked storage area and inaccessible to residents.

Bedrooms: LPA observed accommodations in resident bedrooms and bathrooms for safety, privacy, and comfort. Random resident rooms on all floors (#1003, #2010, #2006, #3003, #3010, #4004, #4006, #5008, #5016, #6016, #6010) were inspected and observed to maintain required furnishing and sufficient lighting, bed linens, and blankets. All bedrooms were observed to be clean and clear from obstruction.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured between 111.0°F and 113.0°F.; within the required range.

Outdoor: Courtyard area observed to have shaded patio(s), with tables with sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility.

[continued on LIC809-C]

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2025 03:33 PM - It Cannot Be Edited


Created By: Raymond Comer On 09/18/2025 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOLLYWOOD HILLS SENIOR LIVING
FACILITY NUMBER: 197609103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(15)
General Food Service Requirements
(b) The following food service requirements shall apply: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as two (2) out of a total five (5) kitchen service staff were not wearing hairnets while inside the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2025
Plan of Correction
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Administrator states that staff shall complete required food preparation hygiene practices re-training, which requires staff to wear hair nets in the kitchen. Proof of training will be sent to LPA, via email, by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Raymond Comer
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: HOLLYWOOD HILLS SENIOR LIVING
FACILITY NUMBER: 197609103
VISIT DATE: 09/18/2025
NARRATIVE
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Staff records: Staff files are stored in Administrator's office; secured and inaccessible to residents. Staff files were reviewed for criminal record clearances, Health Screening, staff associated to this facility, and all required documentation. Staff records appear to be complete and current.

Deficiencies issued during today’s visit. Exit interview conducted, appeal Rights explained. and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 09/18/2025 03:33 PM - It Cannot Be Edited


Created By: Raymond Comer On 09/18/2025 at 02:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOLLYWOOD HILLS SENIOR LIVING
FACILITY NUMBER: 197609103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care- Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with section cited above. LPA observed the medication room open and meds refrigerator accessible, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/28/2025
Plan of Correction
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Meds refrigerator door was immediately locked at the time of LPA observation. Administrator states that staff will complete in-service training regarding access policy to medication room within ten days of this citation. Evidence of completion to be submitted to LPA as of POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Raymond Comer
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
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