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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197601221
Report Date: 09/28/2021
Date Signed: 09/28/2021 02:19:51 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
09/07/2021 and conducted by Evaluator Calvin Tsui
COMPLAINT CONTROL NUMBER: 31-AS-20210907115151
FACILITY NAME:MARBLE TERRACEFACILITY NUMBER:
197601221
ADMINISTRATOR:GODLEWSKA, ELIZABETHFACILITY TYPE:
740
ADDRESS:5811 DONNA AVE.TELEPHONE:
(818) 708-2327
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: DATE:
09/28/2021
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Bozena KozbialTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
1. Staff hit resident in care
2. Staff yelled at resident in care
3. Residents are not assisted with their showers
4. Staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Calvin Tsui and Alex Pritz conducted a subsequent complaint visit at the facility and met with Bonzena Kozbial at around 2:00pm.

On 9/13/21 LPAs Calvin Tsui and Wendell Smith along with Licensing Program Manager Cassandra Harris visited the facility. Interviews where conducted with 6/6 of the residents and resident files where reviewed.

Allegation #1, that "staff hit resident in care," is unsubstantiated based on the interviews conducted. 6/6 residents interviewed on 9/13/21 denied being hit or seeing other residents hit by staff.

Allegation #2, that "staff yelled at resident in care," is unsubstantiated based on the interviews conducted. 6/6 residents interviewed on 9/13/21 denied yelled at by staff.



Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Calvin TsuiTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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 2
Control Number 31-AS-20210907115151
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: MARBLE TERRACE
FACILITY NUMBER: 197601221
VISIT DATE: 09/28/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation #3, that "Residents are not assisted with their showers," is unsubstantiated based on the interviews conducted. 6/6 residents interviewed on 9/13/21 stated that staff where available to assist with showers.

Allegation #4, that "Staff did not safeguard resident's personal belongings," is unsubstantiated based on the interviews conducted. 6/6 residents interviewed on 9/13/21 stated that staff did not touch their personal belongings or otherwise fail to safeguard them.


report reviewed and signed

exit interview conducted.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Calvin TsuiTELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2