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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609103
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:19:16 PM


Document Has Been Signed on 05/10/2022 02:19 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
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: 58DATE:
05/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Vanessa Jewell - Executive DirectorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit to this facility to follow up on the incident reported on 05/04/22 wherein Resident #1 (R1) allegedly touched Resident #2 (R2) inappropriately.

During this visit, LPA conducted physical plant tour at 9:00 AM at the memory care unit, requested copy of facility documents relevant to the investigation and interviewed residents and staff between 10:05 AM to 12:00 PM. LPA's record review at 9:30 AM revealed that R1, R2 and Resident #3 (R3) were residents of Memory Care unit of the facility. LPA's interview with R3 who supposedly witnessed R1 inappropriately touching R2 revealed that R3 was not able to remember the time and date of the supposed incident. LPA interview with Staff #1 (S1) whom R3 called to supposedly stop R1 from touching R2 revealed that S1 did not witness R2 inappropriately touching R1. Further, LPA's interview with R1 also revealed that there was no one touched R1 inappropriately or otherwise.

LPA did not observe any health and safety issue during this visit.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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