197609103-8-25-2021-31-AS-EMIR-CA7VNT-20211230153539

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 08/25/2021
Date Signed: 08/25/2021 02:58:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/23/2021 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210823092812

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: 42	DATE:	08/25/2021
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Vanessa Jewel and Keith Bernabe		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is not isolating a resident who is COVID-19 positive
Facility staff have not notified residents or their responsible parties of confirmed COVID cases

INVESTIGATION FINDINGS:

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An unannounced initial 10 day complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon arrival and entrance to the facility LPA was properly screened for COVID-19 precautions.

In regards to the allegations listed above it was reported that approximately 8/19/2021 resident 1 (R1) and staff 1 (S1) tested positive for COVID. Complainant was concerned because R1 was being quarantined in his room versus the licensees designated COVID unit. It was also reported that the staff failed to provide notification to residents and their responsible parties of the new COVID positive cases.

From approximately 11:55 to 12:15 LPA spoke with Administrator Vanessa Jewell and Resident Services Director Keith Bernabe who provided the following information. On 8/20/2021 R1 demonstrated symptoms of flu/COVID. As a precaution R1 was immediately placed under quarantine and tested for COVID 19. As of LPA's visit the test results are pending. In regards to S1 LPA was informed that S1 was not tested at the facility and they did not receive any notification from staff regarding testing positive. S1's last day of work was 8/19/2021.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

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 4

Control Number 31-AS-20210823092812

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197609103
	VISIT DATE: 08/25/2021

NARRATIVE

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S1 called off from via text on 8/20/2021 and resigned from her employment on 8/21/2021 via text. Administrator and resident services director both confirmed that they have not had any staff or resident who tested positive in 2021. Approximately 2 weeks ago 1 staff member demonstrated flu like symptoms. The staff member was taken off the schedule, tested and the results were negative. According to Ms. Jewell if they receive notification of a confirmed COVID 19 test, she will immediately notify public health, staff will call the families and send out a memo to all residents/staff/responsible parties as they did in 2020.

From approximately 12:20 pm to 12:30 pm LPA walked to the room of the isolated residents and observed proper signs/notices, PPE supplies and trash can placed outside the room.

From approximately 12:35 to 12:50 LPA conducted review of files for S1 and R1. LPA was also provided copy of the pending test result for R1. Upon review of records LPA confirmed the information provided verbally during this visit.

Information obtained during this investigation revealed that there aren't any active COIVD positive residents or staff at the facility, Licensee/Staff are following proper isolation/quarantine guidelines for the symptomatic resident. Since there isn't a confirmed/active COVID case at the facility the licensee/staff are not required to provide notification therefore the allegations are unfounded at this time. This agency has investigated the allegations of Facility is not isolating a resident who is COVID-19 positive and Facility staff have not notified residents or their responsible parties of confirmed COVID cases. We have found that the complaint allegations were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted with Mr.Bernabe and copy of report emailed.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/23/2021 and conducted by Evaluator Yelena Avetisyan

COMPLAINT CONTROL NUMBER: 31-AS-20210823092812

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: 42	DATE:	08/25/2021
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Vanessa Jewell and Keith Bernabe		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff are not wearing a mask

INVESTIGATION FINDINGS:

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An unannounced initial 10 day complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan. Upon arrival and entrance to the facility LPA was properly screened for COVID-19 precautions. The visit was conducted with the administrator Vanessa Jewel and Resident Services Director Keith Bernabe.

In regards to the allegation it was reported that the Administrator, residents, staff, and kitchen staff do not wear a mask, and the facility does not require staff to do so. While entering the facility at 11:40 am LPA observed 2 staff not wearing masks. LPA was directed to a private room where her equipment was set up. Approximately 11:45 am LPA walked towards the dinning room and observed lunch being served. LPA also observed the server not wearing a mask. Approximately 12:30 pm LPA had a discussion with the administrator regarding mask requirement. According to Ms. Jewell and Mr. Bernabe staff are required to wear a mask at all times while working. Mr. Bernabe stated he will provide in service training to all staff immediately, Based on the observations made the allegation is Substantiated. Exit interview conducted with Mr. Barnabe and copy of report issued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20210823092812

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197609103
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/25/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/03/2021 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful... accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Per resident care director he will provide in service training to all staff. Confirmation of the confirmed training will be submitted as POC.
	8 9 10 11 12 13 14	Based on observations made during the complaint investigation visit the staff did not comply with the section cited above by not wearing face mask/covering while working in the facility which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4