197609103-11-29-2021-31-AS-NMAN-CE5254-20220504170451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609103
Report Date: 11/29/2021
Date Signed: 11/29/2021 04:02:46 PM

Unfounded

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
11/23/2021 and conducted by Evaluator LaQueena Lacy

COMPLAINT CONTROL NUMBER: 31-AS-20211123085258

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: 57	DATE:	11/29/2021
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Vanessa Jewell		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Lack of supervision resulting in resident wandering away from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced initial complaint visit to investigate the allegation above. LPA meet with the Administrator and explained the purpose of this visit. LPA conducted a physical plant tour at 1:25pm.
It was alleged that the resident #1 (R1) wander off from the facility and was found on the streets.
During this visit at 2:10pm LPA spoke with the Executive Director (ED) and other staff. Prior to this visit on 11/24/2021 at 10:15am, LPA spoke with ED over the phone and discussed an incident involving R1. Information received revealed that R1 did not wonder from the facility. On 11/15/2021, R1 was sent to the hospital due to difficulty breathing, a few hours later, R1 was discharged from the hospital and was unable to return to the facility due to impaired memory related to Dementia. ED called the hospital for follow up and was notified that R1 left the hospital against medical advice. R1’s family and police were notified. R1 was located by staff through a tracker on R1’s cell phone through R1’s family members cell phone.
At the time of this visit at 3:04pm LPA Lacy spoke with R1’s family member who verified the information received from ED.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

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-20211123085258

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: 11/29/2021

NARRATIVE

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Based on the interviews and document review, it was concluded that R1 never wondered out of the facility. Therefore, the allegation deemed to be UNFOUNDED at this time.
This agency has investigated the complaint alleging “Lack of supervision resulting in resident wandering away from facility”. We have found that the complaint was without a reasonable basis. We have therefore dismissed the complaint.

No health and safety hazard are noted during this visit.

Exit interview was conducted and copy of report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 586-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

LIC9099 (FAS) - (06/04)

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