Inspection Reports for Hollywood Hills Senior Living
1745 N Gramercy Pl, Los Angeles, CA 90028, United States, CA, 90028
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with many complaint investigations unsubstantiated, indicating generally consistent compliance. However, several substantiated issues involved resident supervision, medication management, and staff training, including multiple incidents of residents eloping and missed or delayed medical care. The facility received citations for failing to report incidents properly and for some lapses in kitchen hygiene and medication security. The most recent report from September 18, 2025, noted deficiencies related to kitchen staff not wearing hairnets and unsecured medication storage, posing health and safety risks. While some issues persist, recent annual inspections show improvement in infection control and physical plant conditions, though supervision and documentation remain areas needing attention.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
56% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 67
Capacity: 120
Deficiencies: 2
Sep 18, 2025
Visit Reason
The inspection was an unannounced continuation of the required annual inspection initially conducted on 09/12/2025, focusing on multiple facility domains including fire safety, kitchen hygiene, medication storage, and resident accommodations.
Findings
The facility generally maintained compliance with safety, cleanliness, and resident accommodations standards. However, deficiencies were noted including two kitchen staff not wearing hairnets, an unlocked medication refrigerator accessible to residents, and medication room door left open, posing health and safety risks.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Two out of five kitchen service staff were not wearing hairnets while inside the kitchen area, posing a potential health, safety or personal rights risk to persons in care. | Type B |
| Medication room door was observed open and medication refrigerator accessible, posing an immediate health and safety risk to persons in care. | Type A |
Report Facts
Kitchen staff without hairnets: 2
Census: 67
Total capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 67
Capacity: 120
Deficiencies: 0
Sep 12, 2025
Visit Reason
The visit was an unannounced annual inspection conducted by the Licensing Program Analyst to evaluate the facility's compliance with licensing requirements.
Findings
The facility was inspected for cleanliness, physical plant condition, infection control measures, and resident records. The delayed egress system and infection control plan were found to be in compliance. Resident records reviewed appeared complete and current. The inspection was not fully completed due to time constraints and will be finished at a later date.
Report Facts
Residents receiving hospice care: 15
Bedridden residents: 2
Resident files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Executive Director | Met with Licensing Program Analyst during inspection |
| Raymond Comer | Licensing Program Analyst | Conducted the annual inspection visit |
| Nichelle Gillyard | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 120
Deficiencies: 2
May 16, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that food service personnel were performing duties in an unsanitary manner, including improper food handling, inadequate dishwashing, and failure to wear hair nets.
Findings
The investigation found that while kitchen equipment and food storage areas were properly maintained and clean, the dishwasher temperature gauge was unreadable and daily dishwashing temperatures were not logged. Additionally, two out of three food service staff were observed not wearing gloves, leading to substantiation of the sanitation allegation.
Complaint Details
The complaint alleged that kitchen staff did not practice proper food handling standards, did not wash dishes thoroughly, and did not wear hair nets. The allegation was substantiated based on observations and interviews.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Kitchen dishwasher temperature gauge is unreadable and staff failed to provide a recorded dishwasher temperature log as required. | Type B |
| Two out of three food service staff were found working without required gloves, violating personal hygiene and food service sanitation practices. | Type B |
Report Facts
Facility Capacity: 120
Census: 73
Food Service Staff: 3
Food Service Staff without gloves: 2
Plan of Correction Due Date: May 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during investigation and named in report |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 120
Deficiencies: 1
May 16, 2025
Visit Reason
The visit was a case management inspection to address deficiencies observed during the investigation of complaint #31-AS-20250506094816. The deficiencies were related to the complaint but were not alleged in it.
Findings
The Administrator did not have a fingerprint clearance on file since their date of hire (08/10/20), which is a violation subject to an immediate civil penalty. Citations were issued accordingly.
Complaint Details
The visit was triggered by complaint #31-AS-20250506094816. The deficiencies found were related to the complaint but were not alleged. The Administrator lacked a fingerprint clearance, constituting a substantiated violation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator does not have a criminal record clearance associated with the facility despite being employed since 08/10/20. | Type A |
Report Facts
Census: 73
Total Capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Named in deficiency for lacking fingerprint clearance |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection and issued citations |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 120
Deficiencies: 0
May 6, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations including staff not preventing a viral outbreak and the facility food warmer being in disrepair.
Findings
The investigation found the allegations unsubstantiated. Observations showed proper infection control measures during a gastrointestinal outbreak affecting residents and staff, and the food warmer was tested and found to be working properly within safe temperature ranges.
Complaint Details
The complaint alleged that staff did not prevent a viral outbreak affecting multiple residents and that the facility food warmer was in disrepair but still in use. The investigation found that 32 residents and 8 staff were affected by the GI outbreak, but proper infection control measures were observed. The food warmer was tested and found to be functioning correctly. The allegations were unsubstantiated.
Report Facts
Residents affected by GI outbreak: 32
Staff affected by GI outbreak: 8
Facility capacity: 120
Census: 69
Food warmer temperature: 164
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during investigation |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Capacity: 120
Deficiencies: 0
Apr 4, 2025
Visit Reason
The visit was conducted to verify the Chapter 7 Bankruptcy Report filed by Pacifica Senior Living as reported by the media and to discuss related lawsuits and their impact on the facility.
Findings
The facility management confirmed that despite multiple lawsuits against related entities, there was no financial impact on the facility, residents, or staff. Management communicated changes to staff and residents, and the bankruptcy did not affect the communities as Pacifica Senior Living was no longer the management company.
Report Facts
Capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carl Knepler | Chief Executive Officer | Provided information regarding lawsuits and bankruptcy impact |
| Stacy Barlow | Assistant Program Administrator | Conducted the meeting to verify bankruptcy report |
| Shelley Grace | Assistant Branch Chief, CCLD | Present during the meeting |
| Craig Lundgren | Legal Counsel, CCLD | Present during the meeting |
| Marlene Nelson | Director, Quality Assurance and Risk Management | Present during the meeting |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 120
Deficiencies: 0
Apr 3, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff were not able to provide care services to a resident.
Findings
The investigation found the allegation unsubstantiated based on interviews with staff, residents, the responsible family member, and review of relevant documents, confirming that the resident received proper care and supervision.
Complaint Details
The complaint alleged that staff were not providing care to Resident #1 and were unnecessarily calling 911. The investigation revealed that Resident #1 had dementia and altered mental status, with documented incidents requiring emergency services. Staff and family member interviews supported that care and supervision were adequate. The allegation was unsubstantiated.
Report Facts
Residents interviewed: 7
Incident dates: Unusual Incident Reports dated 3/23/25 and 3/35/25 (likely a typographical error for 3/25/25) describe incidents involving Resident #1.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Named in interviews refuting the allegation and met during the investigation. |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit. |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 120
Deficiencies: 1
Mar 11, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not prevent a resident from eloping while in care.
Findings
The investigation found sufficient evidence to substantiate the allegation that staff failed to prevent a resident with dementia from wandering unattended outside the facility. The facility lacked surveillance cameras but is considering installing them and using tracking fobs to prevent future elopements.
Complaint Details
The complaint was substantiated. The allegation involved Resident #1 wandering unattended outside the facility. Interviews and document reviews confirmed the resident was placed as an Assisted Living resident with frequent observation, but supervision was insufficient to prevent elopement.
Deficiencies (1)
| Description |
|---|
| Staff did not prevent a resident from eloping while in care. |
Report Facts
Facility capacity: 120
Resident census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Vanessa Jewell | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 120
Deficiencies: 0
Mar 10, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations that the facility failed to report suspected abuse and neglect of residents in care.
Findings
The investigation found insufficient evidence to substantiate the allegations of abuse and neglect. Interviews with staff, residents, and family members did not corroborate the claims, and no health or safety issues were observed during the visit.
Complaint Details
The complaint alleged that a staff member held and pushed a pillow over the face of Resident #1 and that Resident #2 was found covered in urine and feces lying on the floor, with neglect attributed to night shift staff. The allegations were refuted by staff supervisors and not corroborated by other staff or residents. The allegation was deemed unsubstantiated.
Report Facts
Complaint Control Number: 31
Number of staff interviewed: 5
Number of residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Keith Bernanbe | Administrator Designee | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 120
Deficiencies: 0
Feb 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that staff did not respond timely to a resident's alerts and did not provide adequate care and supervision.
Findings
The investigation found that six out of seven residents reported timely staff response to service calls, and seven out of seven residents stated staff provided professional and satisfactory care. Therefore, the allegations were deemed unsubstantiated.
Complaint Details
The complaint was unsubstantiated based on interviews and observations. Allegations included staff not responding timely to resident alerts and inadequate care and supervision, both of which were not proven.
Report Facts
Resident interviews: 7
Facility census: 69
Facility capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Keith Barnanbe | Administrator Designee met during the investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 0
Feb 21, 2025
Visit Reason
An unannounced complaint investigation visit was conducted to investigate an allegation of staff physically abusing a resident at the facility.
Findings
The investigation found insufficient evidence to corroborate the allegation of physical abuse by staff against the resident. Interviews with staff, residents, and a family member did not support the claim, and the allegation was deemed unsubstantiated.
Complaint Details
The allegation involved staff physically abusing Resident #1 during a diaper change in January 2025. Multiple staff and residents interviewed denied witnessing or hearing of any abuse. The resident had passed away prior to the investigation. The family member confirmed professional and respectful treatment of the resident. The allegation was unsubstantiated.
Report Facts
Complaint Control Number: 31-AS-20250212131914
Number of staff interviewed: 5
Number of memory care residents interviewed: 4
Number of assisted living residents interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Keith Bernanbe | Administrator designee met during the visit |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 1
Feb 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff spoke inappropriately to a resident.
Findings
The allegation that staff spoke inappropriately to Resident #2 was substantiated based on interviews with staff and the resident. The facility took corrective action by disciplining the caregiver and removing them from providing direct care to the resident.
Complaint Details
The complaint alleged that staff caregiver (S7) yelled at Resident #2 (R2) and acted unprofessionally and rudely. The allegation was substantiated after interviews with staff and the resident. The caregiver received a written warning and was removed from providing direct care to R2.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Personal Rights of Residents in All Facilities-(a) Residents in all residential care facilities shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff. This requirement is not met as evidenced by facility caregiver spoke inappropriately to Resident #2, violating their personal rights, which poses an immediate Health, Safety, or Personal Rights risk to clients in care. | Type A |
Report Facts
Capacity: 120
Census: 68
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Keith Bernanbe | Administrator designee met during the visit |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 1
Feb 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not prevent a resident from eloping while in care.
Findings
The investigation substantiated that Resident 1, diagnosed with dementia, eloped from the facility unsupervised on two occasions, posing a potential health and safety risk. Staff interviews and record reviews confirmed the lack of adequate supervision.
Complaint Details
The complaint alleged that staff did not prevent a resident from eloping. The allegation was substantiated based on records review and interviews. Resident 1 was found wandering outside the facility on two occasions and was returned safely. The facility was notified and plans for staff retraining were made.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| "Care and supervision" requirement not met as staff failed to prevent Resident 1 from eloping unsupervised, endangering resident safety. | Type B |
Report Facts
Capacity: 120
Census: 68
Deficiency count: 1
Plan of Correction due date: Feb 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Keith Bernanbe | Administrator designee | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 0
Feb 14, 2025
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that night shift staff were not meeting the incontinence needs of residents in the memory care unit.
Findings
Observations of resident bedrooms and interviews with staff and residents revealed that all residents appeared clean and dry, with no evidence of neglect in incontinence care. The allegation was deemed unsubstantiated based on these findings.
Complaint Details
The complaint alleged that night shift staff neglected to provide incontinence service assistance to memory care residents. After investigation, including observations and interviews, the allegation was found to be unsubstantiated.
Report Facts
Memory Care Unit census: 29
Staffing during morning and afternoon shifts: 5
Staffing during night shift: 4
Minimum incontinent resident changes per shift: 3
Number of residents interviewed: 7
Number of staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Vanessa Jewell | Administrator | Facility administrator present during the investigation |
| Esmeralda Guevara | Memory Care Director | Provided information about memory care unit staffing and resident care |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 2
Feb 13, 2025
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that staff did not prevent a resident from sustaining a fracture and did not seek medical attention in a timely manner.
Findings
Investigation found that facility staff failed to report a resident's fall incident to supervisory staff and did not provide required medical assessment and treatment in a timely manner, posing an immediate health and safety risk. The allegations were substantiated and a civil penalty was issued.
Complaint Details
The complaint was substantiated. Facility staff failed to prevent a resident from sustaining a fracture and did not seek medical attention in a timely manner. Staff failed to report the fall incident, delayed notifying hospice, and did not conduct proper injury assessments.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Observation of the Resident - Licensee shall ensure residents are regularly observed for changes in physical functioning and appropriate assistance is provided when such observation reveals unmet needs. | Type A |
| Incidental Medical and Dental Care - Licensee shall immediately telephone 9-1-1 if an injury has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis. | Type A |
Report Facts
Civil Penalty: 500
Capacity: 120
Census: 68
Plan of Correction Due Date: Feb 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Named in relation to complaint and investigation findings. |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation. |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 1
Feb 6, 2025
Visit Reason
An unannounced complaint investigation was conducted to investigate the allegation that unqualified staff was providing care and supervision at the facility.
Findings
The investigation substantiated that Staff#1, who functions primarily as a memory care activities assistant, did not have documented proof of completing all required 'in-service' staff trainings, posing a potential health and safety risk to residents.
Complaint Details
The complaint alleged that unqualified staff was providing care and supervision. The allegation was substantiated based on review of Staff#1's employee file and corroborative statements indicating lack of documented proof of completed trainings.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to provide supervisory verification that all facility 'in-service' trainings were completed by Staff#1. | Type B |
Report Facts
Capacity: 120
Census: 68
Plan of Correction Due Date: Feb 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Keith Bernanbe | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 120
Deficiencies: 1
Dec 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations received on 09/28/2023 regarding lack of planned activities, hydration, residents' rights to wear their own clothes, and assistance during overnight shifts.
Findings
Three allegations regarding activities, hydration, and residents' clothing were found unsubstantiated based on interviews and observations. One allegation regarding inadequate assistance during overnight shifts was substantiated due to inconsistent night shift rounds and staffing coverage, posing a potential health and safety risk.
Complaint Details
The complaint investigation was triggered by allegations that staff did not provide planned activities, hydration between meals, residents' right to wear their own clothes, and assistance during overnight shifts. The first three allegations were unsubstantiated, while the allegation about overnight assistance was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Care of Persons with Dementia: There is an inadequate number of direct care staff to support each resident’s physical, social, emotional, and safety needs during the night shift. | Type B |
Report Facts
Capacity: 120
Census: 72
Plan of Correction Due Date: Jan 2, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with during the investigation and informed of the visit reason |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the complaint investigation |
| Troy Agard | Licensing Program Manager | Conducted the complaint investigation and issued citation |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 0
Dec 6, 2024
Visit Reason
The visit was conducted to investigate multiple allegations received on 2024-09-30 regarding inadequate incontinence care, lack of laundry service, and improper medication distribution at Pacifica Senior Living Hollywood Hills.
Findings
Based on records review, staff and resident interviews, and observations, all allegations were found to be unsubstantiated. Staff provide incontinence care, laundry service, and medication administration as prescribed, although some residents expressed frustration with response times and service frequency.
Complaint Details
The complaint investigation was unannounced and focused on allegations that staff did not meet residents' incontinence needs, failed to provide laundry service, and did not distribute medications as prescribed. After thorough investigation, all allegations were determined to be unsubstantiated.
Report Facts
Facility capacity: 120
Resident census: 120
Complaint receipt date: Sep 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and inspection |
| Vanessa Jewell | Administrator | Facility administrator interviewed during investigation |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 120
Deficiencies: 0
Nov 5, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff did not respond timely to a resident's alerts and did not provide adequate care and supervision.
Findings
The investigation found that staff did respond timely to resident service calls and provided adequate care and supervision. Interviews, observations, and record reviews did not substantiate the allegations, which were deemed unsubstantiated.
Complaint Details
The complaint alleged that staff failed to respond timely to a resident's service call button and did not provide adequate care and supervision. The investigation found no evidence to support these allegations, and they were unsubstantiated.
Report Facts
Capacity: 120
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during the investigation and mentioned in findings |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 120
Deficiencies: 0
Oct 29, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2023-08-22 regarding unexplained bruises on a resident and staff not safeguarding a resident's personal belongings.
Findings
The investigation found the allegations unsubstantiated based on staff interviews, records review, and external observations including a police health check and hospice staff input. No suspicious injuries or evidence of staff negligence were found.
Complaint Details
The complaint involved two allegations: 1) Resident sustained multiple unexplained bruises; 2) Staff did not safeguard resident’s personal belongings. Both allegations were deemed unsubstantiated after review of medical records, staff interviews, and external checks.
Report Facts
Capacity: 120
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during investigation |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 0
Oct 1, 2024
Visit Reason
The visit was conducted as a complaint investigation following allegations of insufficient staff supervision leading to residents entering other residents' rooms and inadequate food service resulting in a resident missing breakfast.
Findings
Based on observations, records review, and interviews with residents and staff, both allegations were found to be unsubstantiated. Staffing levels were deemed sufficient to prevent unauthorized room entry and to provide adequate food service.
Complaint Details
The complaint alleged that staff did not supervise residents adequately, causing residents to enter other residents' rooms, and that staff did not provide adequate food service, resulting in a resident missing breakfast. Both allegations were investigated and found unsubstantiated.
Report Facts
Resident interviews: 7
Staff interviews: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Facility administrator contacted during investigation |
| Keith Bernanbe | Administrator Designee | Assisted Licensing Program Analyst during complaint investigation |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
| Delaila Betancourt | Business Office Manager | Facilitated contact with Administrator during investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 120
Deficiencies: 0
Sep 24, 2024
Visit Reason
The visit was conducted to investigate complaints alleging staff mismanagement of resident medication and insufficient staffing to meet resident needs at Pacifica Senior Living Hollywood Hills.
Findings
The investigation included records review, staff and resident interviews, and a physical plant tour. Both allegations were found to be unsubstantiated based on evidence that medication was administered as prescribed with a corrected notation error, and staffing levels were adequate to meet resident needs.
Complaint Details
The complaint investigation was unannounced and focused on two allegations: medication mismanagement and insufficient staffing. After review and interviews, both allegations were determined to be unsubstantiated.
Report Facts
Residents interviewed: 8
Staff interviewed: 2
Medical Technicians minimum per shift: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during investigation |
| Raymond Comer | Licensing Program Analyst | Conducted complaint investigation |
| Eva Miller | Licensing Program Manager | Oversaw complaint investigation |
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 1
Sep 20, 2024
Visit Reason
The visit was a subsequent complaint investigation related to complaint #31-AS-20240724164758, conducted to assess compliance and investigate deficiencies at the facility.
Findings
The investigation found that the facility's documentation retention policy was not in compliance with California Title 22 requirements, as records were only retained for 90 days instead of the required minimum of three years, representing a potential health and safety issue.
Complaint Details
The visit was triggered by complaint #31-AS-20240724164758. The deficiency related to records retention was substantiated during the investigation.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The Licensee's Documentation Retention Policy only allows retention of documents for a minimum of 90 days and then records are destroyed, which conflicts with the requirement to retain original records or photographic reproductions for a minimum of three years following termination of service. | Type B |
Report Facts
Capacity: 120
Retention period: 90
Retention period required: 1095
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Eva Miller | Licensing Program Manager | Supervisor overseeing the inspection |
| Vanessa Jewell | Administrator/Director | Facility Administrator present during the inspection |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 120
Deficiencies: 0
Sep 20, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff did not assist a resident with mobility needs in a timely manner.
Findings
The investigation found that the allegation was unsubstantiated. Staff addressed the resident's wheelchair issue on the same day it was reported, and the resident confirmed their mobility needs were met timely.
Complaint Details
The complaint alleged that staff did not assist Resident #1 with mobility needs promptly due to a loose wheelchair leg pad causing irritation. Interviews and observations confirmed the issue was resolved the same day, and the allegation was unsubstantiated.
Report Facts
Capacity: 120
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during investigation and involved in addressing the resident's wheelchair issue |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 120
Deficiencies: 1
Sep 6, 2024
Visit Reason
The visit was conducted as a case management visit in conjunction with a complaint investigation related to a theft of a resident's personal belongings.
Findings
The facility failed to report the theft of a resident's personal property to law enforcement within the required timeframe, violating theft and loss policies. The deficiency was addressed during the visit by implementing staff in-service training.
Complaint Details
The complaint investigation was related to theft of resident #1's personal belongings. The facility did not comply with reporting requirements to law enforcement, which posed a potential personal rights risk to residents.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report theft of resident property valued at $100 or more to local law enforcement within 36 hours as required by facility policy. | Type B |
Report Facts
Capacity: 120
Census: 74
POC Due Date: Sep 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met during inspection and involved in interview regarding theft reporting deficiency |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection and complaint investigation |
| Eva Miller | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 120
Deficiencies: 0
Sep 6, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding an allegation that staff did not safeguard a resident's personal belongings, specifically jewelry items belonging to Resident #1.
Findings
The investigation found that the facility has theft and loss policies prominently posted and staff are trained on these policies. Resident files showed acknowledgment of these policies. Interviews with residents denied the allegation, and there was no preponderance of evidence to prove the alleged violation. Therefore, the complaint was unsubstantiated.
Complaint Details
The complaint alleged that staff did not safeguard Resident #1's personal belongings, specifically jewelry items, which were reported stolen. After investigation including interviews and record reviews, the allegation was found unsubstantiated.
Report Facts
Resident files reviewed: 7
Residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during the investigation and provided statements |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation and site visits |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 120
Deficiencies: 1
Aug 22, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to allegations that the facility was in disrepair and that personnel requirements, specifically annual First Aid training for staff, were not being met.
Findings
The allegation of facility disrepair was unsubstantiated after physical inspection and interviews, with no health and safety issues observed. However, the allegation that annual First Aid training was not provided to staff was substantiated, with training pending and scheduling efforts in progress.
Complaint Details
The complaint investigation included two allegations: 1) Facility is in disrepair, which was unsubstantiated; 2) Personnel requirements not met, specifically annual First Aid training not completed, which was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| First aid training not completed for facility staff as required by CCR 87411(c)(1) Personnel Requirements-General. | Type B |
Report Facts
Capacity: 120
Census: 74
Deficiencies cited: 1
Plan of Correction Due Date: Sep 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during investigation and provided information regarding allegations |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 120
Deficiencies: 0
Aug 16, 2024
Visit Reason
The visit was conducted as a complaint investigation following a complaint received on 07/24/2024 alleging that staff was providing false information to residents.
Findings
Interviews with residents and staff did not corroborate the allegation. Six of seven residents and five of seven staff stated they had neither heard nor witnessed the Administrator providing false information. The allegation was determined to be unsubstantiated based on observations, interviews, and document review.
Complaint Details
The complaint alleged that staff was providing false information to residents. The investigation found no preponderance of evidence to substantiate the allegation, and it was deemed unsubstantiated.
Report Facts
Residents interviewed: 7
Residents denying allegation: 6
Staff interviewed: 7
Staff denying allegation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Named in relation to the allegation of providing false information to residents |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 120
Deficiencies: 0
Jul 2, 2024
Visit Reason
The visit was conducted to investigate a complaint alleging that staff did not comply with reporting requirements related to an injury sustained by a resident.
Findings
The investigation found that staff were aware of the resident's injury and submitted the required incident report in a timely manner according to regulations. The allegation that staff failed to follow proper reporting requirements was unsubstantiated.
Complaint Details
The complaint alleged that staff did not submit an incident report for a resident injury as required by Title 22 reporting requirements. The allegation was found to be unsubstantiated after review of documents and interviews.
Report Facts
Capacity: 120
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during investigation and provided information regarding the allegation |
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Annual Inspection
Census: 72
Capacity: 120
Deficiencies: 0
Jun 7, 2024
Visit Reason
The inspection visit was an unannounced continuation of the required 1 Year Annual Inspection conducted on 06/06/2024 to observe, review, and inspect remaining inspection domains at the facility.
Findings
The facility was found to have no immediate health and safety hazards. Fire detection and protection systems were functional and maintained, kitchen and medication storage met requirements, laundry and common areas were clean and safe, resident bedrooms and bathrooms were properly equipped and maintained, and resident and staff records were complete and current.
Report Facts
Hot water temperature: 114.5
Fire extinguisher last service date: Jun 30, 2023
Fire drill last conducted: May 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during inspection |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection visit |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 72
Capacity: 120
Deficiencies: 0
Jun 6, 2024
Visit Reason
The inspection was an unannounced required annual visit and inspection of the facility conducted by the Licensing Program Analyst.
Findings
The facility was inspected for cleanliness, condition, infection control protocols, and resident records. Resident records appeared complete and current. The annual inspection was not fully completed due to time constraints and will be completed at a later date.
Report Facts
Residents receiving hospice care: 6
Bedridden residents: 2
Disaster drills last conducted: May 15, 2024
Resident files reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during inspection and named in exit interview |
| Raymond Comer | Licensing Program Analyst | Conducted the inspection visit |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 0
Apr 16, 2024
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that staff were not assisting a resident with incontinence needs, did not respond to the resident's call button in a timely manner, and did not allow the resident to manage their own medication.
Findings
The investigation found that the resident was not allowed to self-administer medications due to safety concerns confirmed by the resident's physician and service plan. The allegation regarding untimely response to call buttons and incontinence needs was unsubstantiated based on resident interviews and observations.
Complaint Details
The complaint was unsubstantiated. Allegations included staff not assisting with incontinence needs, delayed response to call button, and restricting resident from managing own medication. Observations and interviews did not support these allegations.
Report Facts
Response time to service call: 9
Number of residents interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Raymond Comer | Licensing Program Analyst | Conducted the complaint investigation visit |
| Micheal Cava | Licensing Program Analyst | Conducted the complaint investigation visit |
| Vanessa Jewell | Executive Director | Met with LPAs during investigation |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 120
Deficiencies: 2
Feb 26, 2024
Visit Reason
An unannounced complaint investigation was conducted to investigate allegations that staff were not dispensing medication as prescribed and that staff did not respond to resident call buttons in a timely manner.
Findings
The investigation substantiated that a resident missed a dose of METFORMIN 500 MG on February 18, 2024, due to delayed medication delivery and failure to report the incident. Another allegation regarding staff response to call buttons was unsubstantiated based on observations and interviews.
Complaint Details
The complaint investigation was substantiated regarding missed medication dose due to delayed delivery and lack of incident reporting. The allegation about delayed staff response to call buttons was unsubstantiated after interviews and observations.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Licensee failed to provide a required SIR regarding missed medication dose, posing a potential health and safety risk to residents. | Type B |
| Licensee did not comply with assisting residents with self-administered medications, evidenced by missed dose of METFORMIN on 02/18/24, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 120
Census: 73
Deficiencies cited: 2
Plan of Correction Due Date: Mar 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Executive Director | Met with Licensing Program Analyst during investigation and named in findings |
| Mariana Agban | Licensing Program Analyst | Conducted the complaint investigation |
| Eva Miller | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 120
Deficiencies: 0
Jan 19, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility's central heating system was not working.
Findings
The investigation found that the central heating system was not working on the fourth and sixth floors of the assisted living portion, but the facility maintained a comfortable temperature using portable heaters and timely repairs. The allegation was substantiated without deficiency.
Complaint Details
The complaint was substantiated. The heating system issues were limited to two floors, with mitigation measures in place including portable heaters and frequent repairs. Residents interviewed mostly reported no heating issues.
Report Facts
Residents interviewed: 7
Service reports reviewed: 8
Additional tower heaters purchased: 7
Floors with heating issues: 2
Residents reporting heating issues: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Reed | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Vanessa Jewell | Administrator | Facility administrator met with the Licensing Program Analyst during the investigation. |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 120
Deficiencies: 2
Jan 3, 2024
Visit Reason
An unannounced complaint investigation visit was conducted due to allegations that the facility did not prevent a resident from developing a stage 4 pressure injury and did not seek medical attention in a timely manner.
Findings
The investigation substantiated that Resident #1 developed prohibited health conditions including multiple pressure injuries while in care. The facility failed to seek proper medical attention or a higher level of care in a timely manner, resulting in significant health risks to the resident.
Complaint Details
The complaint was substantiated. The facility failed to prevent the development of a stage 4 pressure injury and did not seek timely medical attention for Resident #1, resulting in prohibited health conditions and delayed hospital transfer.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility retained a resident with Stage 4 and unstageable pressure injuries, posing immediate health, safety, and personal rights risks. | Type A |
| Facility did not allow an ambulance to take Resident #1 to the hospital immediately and receive medical care, posing an immediate health and safety risk. | Type A |
Report Facts
Facility capacity: 120
Census: 76
Deficiencies cited: 2
Plan of Correction due date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Venessa Jewell | Executive Director | Named in relation to accepting the amended report and facility administration |
| Jana Mahany | Marketing Director | Met with Licensing Program Analyst during investigation and designated to sign and accept report |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 120
Deficiencies: 1
Oct 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation following an allegation that residents wandered away due to lack of supervision.
Findings
The investigation substantiated the allegation that a resident eloped from the memory care unit due to staff failing to ensure the elevator was properly secured and locked, posing a potential health and safety risk.
Complaint Details
The complaint was substantiated. Resident #1 eloped from the memory care unit on 09/21/2023 and was missing for several hours before being returned by police. Staff did not ensure the elevator was locked, contributing to the elopement.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Care of Persons with Dementia: Failure to ensure the continued safety of residents if they wander away from the facility, evidenced by a resident eloping due to the elevator not being locked and secured. | Type B |
Report Facts
Capacity: 120
Census: 76
Plan of Correction Due Date: Oct 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tuesday Cabiness | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Vanessa Jewell | Administrator | Facility administrator interviewed during investigation and agreed to submit plan of correction |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 120
Deficiencies: 1
Oct 5, 2023
Visit Reason
The visit was a case management inspection conducted in conjunction with complaint number 31-AS-20230928100059 to investigate an incident involving a resident eloping from the memory care unit.
Findings
The facility failed to report the elopement incident of resident #1 as required, submitting invalid documentation that did not match the incident report, resulting in a citation for failure to report.
Complaint Details
The visit was triggered by complaint number 31-AS-20230928100059. The complaint was substantiated by the finding that the facility did not report the elopement incident as required.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to submit a required Serious Incident Report (SIR) for resident #1 who eloped from the memory care unit, violating reporting requirements. | Type B |
Report Facts
Capacity: 120
Census: 76
Plan of Correction Due Date: Oct 12, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Facility administrator present during the inspection |
| Tuesday Cabiness | Licensing Program Analyst | Conducted the case management visit and investigation |
| Troy Agard | Licensing Program Manager | Named as Licensing Program Manager overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 120
Deficiencies: 0
Aug 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-04-28 regarding emergency lighting availability, staff assistance during meals, and resident injuries due to staff neglect.
Findings
The investigation found insufficient evidence to substantiate the allegations related to emergency lighting, meal assistance, and resident injuries. Observations and interviews confirmed emergency lighting was available, staff provided appropriate meal assistance, and the resident's injuries were not linked to staff neglect. No deficiencies or health and safety hazards were cited.
Complaint Details
The complaint involved three main allegations: lack of emergency lighting during an emergency, improper staff assistance during meals, and resident injuries due to staff neglect. All allegations were found to be unsubstantiated after interviews, observations, and record reviews.
Report Facts
Complaint Control Number: 31-AS-20230428113611
Number of residents interviewed: 5
Number of residents requiring standby assistance during meals: 3
Number of staff assisting residents during meals: 1
Number of residents prompted to eat: 2
Number of residents fed by staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LaQueena Lacy | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation report |
| Gerard Palmos | Staff member met during the investigation | |
| Vanessa Jewell | Administrator | Interviewed during the investigation |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 120
Deficiencies: 0
Aug 23, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2022-05-13 regarding insufficient staffing and neglect leading to a resident's wound infection.
Findings
Based on observations, interviews, and record review, there was insufficient evidence to substantiate the allegations of inadequate staffing and neglect causing a resident's wound infection. No health and safety hazards were noted and no deficiencies were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included that resident needs were not met due to lack of staffing and that neglect caused a resident wound infection. Interviews with residents and staff, as well as record reviews, did not corroborate these allegations.
Report Facts
Capacity: 120
Census: 74
Complaint control number: 31-AS-20220513091519
Dates of hospice care visits: 2
Dates of hospice care visits: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LaQueena Lacy | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
| Gerard Palmos | Staff member met during the investigation | |
| Vanessa Jewell | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 120
Deficiencies: 0
Aug 16, 2023
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff over medicated a resident in care.
Findings
The investigation found no sufficient evidence to support the allegation. Records showed the resident had not been given the alleged medication for over a month, and staff interviews confirmed medication was administered only as needed. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that staff over medicated a resident. The investigation included document review, physical plant tour, and staff interviews. The allegation was found to be unsubstantiated.
Report Facts
Census: 32
Total Capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation |
| Maria Roleda | Resident Service Director | Met with Licensing Program Analyst during investigation |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 120
Deficiencies: 0
May 7, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2023-02-21 regarding resident personal belongings not being safeguarded, residents being left soiled, a resident injury from a fall, and insufficient staffing.
Findings
After interviews, record reviews, and observations, none of the allegations were substantiated. There was no evidence of missing belongings, residents left soiled, fall injuries, or insufficient staffing. Staff and residents reported adequate care and staffing levels, and no health and safety hazards were noted during the visit.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included missing resident belongings, residents left soiled for extended periods, resident injury from a fall, and insufficient staffing. Investigations included interviews with staff, residents, and other parties, document reviews, and physical plant tours. No evidence was found to verify the allegations.
Report Facts
Capacity: 120
Census: 76
Care staff in Assisted Living: 3
Care staff in Memory Care: 3
Residents in Assisted Living: 53
Residents in Memory Care: 23
MedTech staff: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
| Maria Roleda | Resident Services Coordinator | Facility representative who met with the Licensing Program Analyst and accepted the report |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 120
Deficiencies: 1
May 5, 2023
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2023-04-28 regarding the facility staff not providing non-slip mats for residents' showers.
Findings
The investigation found that the facility staff do not provide non-slip mats to residents, with only 2 out of 13 observed bedrooms having non-slip mats in the bathroom showers. The allegation was substantiated, but no health and safety hazards were noted during the visit.
Complaint Details
The complaint was substantiated based on observations and interviews confirming the lack of non-slip mats in residents' showers.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide non-skid mats or strips in all bathtubs and showers as required by CCR 87303(a)(5). | Type B |
Report Facts
Deficiencies cited: 1
Rooms observed: 13
Rooms with non-slip mats: 2
Plan of Correction due date: May 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met with Licensing Program Analyst during investigation and confirmed lack of non-slip mats |
| LaQueena Lacy | Licensing Program Analyst | Conducted the complaint investigation visit |
| Naira Margaryan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 120
Deficiencies: 0
Apr 26, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that residents were being mistreated while in care.
Findings
The investigation found no evidence of mistreatment or neglect. Interviews with staff and residents, as well as record reviews, did not substantiate the allegations. No health and safety hazards were noted during the visit.
Complaint Details
The complaint alleged mistreatment of residents. The allegation was unsubstantiated based on interviews and record review.
Report Facts
Staff interviewed: 3
Residents interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Executive Director | Met with Licensing Program Analyst during investigation |
| Abeye Duguma | Licensing Program Analyst | Conducted the complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 120
Deficiencies: 1
Feb 1, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the heater was not working in residents' rooms on the 3rd floor.
Findings
The investigation found that the heating system on the 3rd floor had been malfunctioning since December 12, 2022, affecting four out of eight occupied bedrooms. The facility had an ongoing heating and air conditioning issue since July 2022 and had failed to correct the problem following a previous complaint investigation in September 2022. The allegation was substantiated.
Complaint Details
The complaint investigation was substantiated based on interviews, record review, and observations. The facility had an ongoing heating issue since July 2022 and failed to correct the problem after a prior complaint investigation on 09/23/2022.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services...(b) A comfortable temperature for residents shall be maintained at all times. This requirement is not met as evidenced by the heater not working on half of the 3rd floor as of 12/12/2022, posing a potential health and safety risk. | Type B |
Report Facts
Capacity: 120
Census: 66
Deficiency Type: 1
Plan of Correction Due Date: Feb 15, 2023
Affected rooms: 4
Occupied rooms on 3rd floor: 8
Residents interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LaQueena Lacy | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
| Gerard Palmos | Memory Care Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 120
Deficiencies: 0
Sep 30, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility was not providing residents with an adequate quantity of food and that the air conditioning was not in proper working condition in residents' rooms.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Residents reported adequate and sufficient food with variety and nutrition, and the facility had addressed air conditioning issues on the 3rd floor by providing portable air conditioners and initiating repairs. Temperatures in inspected rooms were within regulatory range.
Complaint Details
The complaint investigation was unannounced and conducted on 09/30/2022. The allegations were unsubstantiated based on observations, interviews, and record reviews.
Report Facts
Facility capacity: 120
Resident census: 63
Number of residents interviewed: 6
Number of rooms inspected: 7
Date of air conditioner purchase: Sep 3, 2022
Date of service report: Sep 16, 2022
Date work started: Sep 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Executive Director | Met with LPAs during the investigation and confirmed air conditioning issues |
| LaQueena Lacy | Licensing Program Analyst | Conducted the complaint investigation |
| Gary Tan | Licensing Program Analyst | Assisted in conducting the complaint investigation |
| Staff #1 | Confirmed air conditioning issues on the 3rd floor |
Inspection Report
Annual Inspection
Census: 59
Capacity: 120
Deficiencies: 0
Jun 16, 2022
Visit Reason
The inspection was a required one-year unannounced infection control visit to assess compliance with infection prevention and control measures.
Findings
The facility was found to be in compliance with infection control standards, with no deficiencies cited. Observations included proper signage, PPE availability, clean and well-maintained kitchen, bedrooms, bathrooms, medication storage, and common areas. Fire safety equipment was tested and passed.
Report Facts
Facility capacity: 120
Census: 59
Medication carts observed: 3
Bathrooms observed: 7
Bedrooms observed: 7
First aid kits: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Facility administrator met with Licensing Program Analyst during inspection |
| LaQueena Lacy | Licensing Program Analyst | Conducted the inspection and authored the report |
| Naira Margaryan | Licensing Program Manager | Named in report header and signature section |
| Gerard Palmos | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 120
Deficiencies: 1
May 23, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility did not issue a refund to the authorized representative upon a resident's death.
Findings
The investigation substantiated that the facility failed to issue a refund in the correct amount to the resident's Power of Attorney after the resident passed away, which may pose a potential health and safety risk to clients in care.
Complaint Details
The complaint was substantiated. The allegation was that the facility charged $2,200 for extended level of care while the resident was hospitalized and did not refund the remainder of the rent. The facility refunded only a prorated amount for two days of March after a 30-day notice was given, but the resident passed away before the notice period ended. The admission agreement states termination upon death. The facility cleared the resident's room before the 30-day notice period ended. The investigation concluded the allegation was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to terminate admission agreement upon death of resident without requiring advance notice and failure to issue refund in the correct amount to resident's POA. | Type B |
Report Facts
Refund amount charged: 2200
Census: 61
Total Capacity: 120
Plan of Correction Due Date: Jun 7, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LaQueena Lacy | Licensing Program Analyst | Conducted the complaint investigation visit |
| Vanessa Jewell | Administrator | Facility administrator met during investigation |
Inspection Report
Census: 58
Capacity: 120
Deficiencies: 0
May 10, 2022
Visit Reason
The visit was an unannounced case management follow-up on an incident reported on 2022-05-03 involving a missing booklet of coin collection belonging to Resident #1.
Findings
The Licensing Program Analyst conducted interviews and a physical plant tour, confirming that the missing item was not declared on the resident's inventory list. The Executive Director reported the incident to the police and conducted an internal investigation and staff in-service. No health and safety issues were observed during the visit.
Report Facts
Capacity: 120
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Executive Director | Interviewed regarding the incident and investigation |
| Jose Gary Tan | Licensing Program Analyst | Conducted the unannounced case management visit |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 120
Deficiencies: 0
May 10, 2022
Visit Reason
Unannounced case management visit to follow up on an incident reported on 2022-05-04 involving an allegation that Resident #1 inappropriately touched Resident #2.
Findings
Interviews and record reviews did not substantiate the allegation of inappropriate touching. No health and safety issues were observed during the visit.
Complaint Details
The complaint involved an allegation that Resident #1 touched Resident #2 inappropriately. Interviews with residents and staff did not confirm the incident, and the complaint was not substantiated.
Report Facts
Residents in Memory Care Unit: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gary Tan | Licensing Program Analyst | Conducted the unannounced case management visit and interviews. |
| Vanessa Jewell | Executive Director | Facility administrator met during the visit. |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 120
Deficiencies: 0
Dec 29, 2021
Visit Reason
The visit was an unannounced case management follow-up on a self-reported incident by the facility that occurred on 12/24/2021 involving an allegation of resident abuse.
Findings
The investigation included interviews and a body and skin check of the resident, which revealed no bruising or concerns. The resident denied the incident, but further investigation was deemed necessary based on documents and interviews.
Complaint Details
The complaint involved an allegation that a resident was manhandled and assaulted by another individual. The resident denied the incident, and no physical evidence was found. The Licensing Program Analyst determined further investigation was required.
Report Facts
Facility capacity: 120
Census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gerard Palmos | Resident Service Coordinator | Spoke with Licensing Program Analyst during the visit |
| LaQueena Lacy | Licensing Program Analyst | Conducted the unannounced case management visit and investigation |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 120
Deficiencies: 0
Nov 29, 2021
Visit Reason
An unannounced complaint investigation was conducted to investigate an allegation of lack of supervision resulting in a resident wandering away from the facility.
Findings
Based on interviews and document review, it was concluded that the resident did not wander away from the facility. The complaint was found to be without a reasonable basis and was dismissed. No health and safety hazards were noted during the visit.
Complaint Details
The complaint alleged lack of supervision resulting in resident wandering away from the facility. The allegation was investigated and deemed unfounded after confirming the resident left the hospital against medical advice and was located by staff using a cell phone tracker.
Report Facts
Complaint Control Number: 31
Complaint received date: Nov 23, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LaQueena Lacy | Licensing Program Analyst | Conducted the complaint investigation visit |
| Vanessa Jewell | Administrator | Facility administrator met with Licensing Program Analyst during visit |
| Naira Margaryan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Census: 51
Capacity: 120
Deficiencies: 0
Nov 15, 2021
Visit Reason
Unannounced case management visit to follow up on a self-reported incident that occurred on 2021-11-10 involving a resident.
Findings
No immediate health and safety issues were noted during the visit. Further investigation was determined to be required based on documents obtained.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LaQueena Lacy | Licensing Program Analyst | Conducted the unannounced case management visit and physical plant tour. |
| Vanessa Jewell | Administrator | Facility administrator met with Licensing Program Analyst during the visit. |
| Naira Margaryan | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Follow-Up
Census: 51
Capacity: 120
Deficiencies: 0
Nov 15, 2021
Visit Reason
Unannounced case management visit to follow up on an incident that occurred on 9/11/21 involving a resident found outside the facility.
Findings
No immediate health and safety issues were noted during the visit. Further investigation is required based on documents obtained.
Report Facts
Incident date: Sep 11, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Executive Director | Interviewed during visit and facility administrator |
| Keith Bernabe | Resident Service Director | Interviewed during visit |
| LaQueena Lacy | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 120
Deficiencies: 1
Aug 25, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that the facility was not isolating a COVID-19 positive resident and staff had not notified residents or responsible parties of confirmed COVID cases, as well as allegations that facility staff were not wearing masks.
Findings
The investigation found the allegations regarding failure to isolate a COVID-19 positive resident and failure to notify were unfounded as there were no active COVID-19 cases at the time and proper isolation/quarantine procedures were followed. However, the allegation that staff were not wearing masks was substantiated based on observations of staff not wearing masks, posing a potential health and safety risk.
Complaint Details
The complaint investigation was initiated due to allegations that the facility was not isolating a COVID-19 positive resident and staff had not notified residents or responsible parties of confirmed COVID cases, and that staff were not wearing masks. The first allegations were found to be unfounded, while the mask-wearing allegation was substantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful accommodations, furnishings and equipment. Staff did not comply by not wearing face masks while working, posing a potential health, safety and personal rights risk to residents. | Type B |
Report Facts
Capacity: 120
Census: 42
Deficiencies cited: 1
Plan of Correction Due Date: Sep 3, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Administrator | Met during investigation and provided information regarding COVID-19 cases and mask policy |
| Keith Bernabe | Resident Services Director | Met during investigation and provided information regarding COVID-19 cases and mask policy; stated he would provide in-service training to staff |
| Yelena Avetisyan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Eva Miller | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 120
Deficiencies: 0
Aug 24, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility charged a $2,000 fee for a resident and then refused to admit the resident.
Findings
The investigation found no sufficient information to support the allegation, which was therefore unsubstantiated. No health and safety hazards were noted during the visit.
Complaint Details
The complaint alleged that the facility charged a $2,000 community fee for Resident #1 and then refused admission. The investigation revealed that the resident was not admitted due to changes in health condition and that the fee was refunded. The allegation was unsubstantiated.
Report Facts
Community fee charged: 2000
Complaint control number: 31-AS-20200605113900
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caroline McColl | Executive Director | Interviewed during the complaint investigation |
| Rosaura Valenzuela | Licensing Program Analyst | Conducted the complaint investigation |
| Naira Margaryan | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 120
Deficiencies: 0
Aug 5, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations including unqualified staff providing care, residents being left on the floor for extended periods, and facility staffing shortages.
Findings
Based on interviews and record review, there was insufficient information to support the allegations, and all were determined to be unsubstantiated at this time.
Complaint Details
The complaint investigation addressed multiple allegations such as unqualified staff providing care, residents left on the floor for extended periods, and staffing shortages. The investigation found no sufficient evidence to substantiate these allegations.
Report Facts
Capacity: 120
Census: 38
Staffing: 3
Staffing: 1
Staffing: 2
Resident count in memory care and assisted living units: 13
Inspection Report
Annual Inspection
Census: 34
Capacity: 120
Deficiencies: 0
Jun 24, 2021
Visit Reason
The inspection was an unannounced required annual inspection conducted to evaluate compliance with licensing and infection control requirements.
Findings
The facility was found to be in compliance with no deficiencies cited. All residents and staff are fully vaccinated, and COVID-19 mitigation procedures including isolation, quarantine, and PPE use are properly implemented and maintained.
Report Facts
Staff COVID-19 testing percentage: 25
Residents in memory care: 17
PPE inventory frequency (days): 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Jewell | Executive Director | Met with Licensing Program Analyst during entrance and exit interviews |
| Martina Berry | Licensing Program Analyst | Conducted the inspection and authored the report |
| Eva Miller | Licensing Program Manager | Named in report as Licensing Program Manager |
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