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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 02:20:03 PM


Document Has Been Signed on 05/10/2022 02:20 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:
12:00 PM
MET WITH:Vanessa Jewell - Executive DirectorTIME COMPLETED:
02:30 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 05/03/22 wherein Resident #1 (R1) lost a booklet of coin collection in the facility.

LPA conducted physical plant tour at 12:05 PM, requested copies of facility documents relevant to the investigation at 12:30 PM and interviewed staff and resident between 12:30 PM to 2:00 PM. LPA's record review at 12:35 AM revealed that R1 did not declare the missing item on the facility Resident Property and Valuables inventory list (LIC 621). LPA's interview with R1 confirmed that R1 did not declare this item on the inventory list. Further interview with R1 also revealed that no one knew about R1's coin collection and that the police came to R1 and interviewed R1 regarding the missing item. LPA's interview with Executive Director revealed that she did report to the police as per their policy and that she immediately conducted an investigation and in service to all staff.

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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