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Department of
SOCIAL SERVICES
Community Care Licensing
COMPLAINT INVESTIGATION REPORT
Facility Number:
197601221
Report Date:
12/17/2021
Date Signed:
12/17/2021 01:08:09 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
Wendell Smith
COMPLAINT CONTROL NUMBER:
31-AS-20210907115151
FACILITY NAME:
MARBLE TERRACE
FACILITY NUMBER:
197601221
ADMINISTRATOR:
GODLEWSKA, ELIZABETH
FACILITY TYPE:
740
ADDRESS:
5811 DONNA AVE.
TELEPHONE:
(818) 708-2327
CITY:
TARZANA
STATE:
CA
ZIP CODE:
91356
CAPACITY:
6
CENSUS:
6
DATE:
12/17/2021
UNANNOUNCED
TIME BEGAN:
11:30 AM
MET WITH:
Bozena Kozbial
TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hit resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit. LPA met with the administrator and explained the reason for this visit.
LPA conducted a physical plant walk through and did not observe any immediate health and safety issues.
It is alleged that resident #1 (R1) was hit by staff # 1(S1)
Previous visits regarding the allegation above was conducted on 9/13/21 and 9/28/21 and interviews were conducted with all residents in the facility. A finding of Unsubstantiated was given on the allegation above. However after review by management it was found that more interviews needed to be conducted. During today's visit LPA conducted interviews with facility staff regarding the allegation above from approximately 11:45am-12:30pm. Information obtained through interviews with staff present reveal they have never witnessed R1 hit by S1 or any other staff. Based on the information obtained this allegation is still deemed Unsubstantiated as it was before. Exit Interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME:
Cassandra Harris
TELEPHONE:
(818) 596-4342
LICENSING EVALUATOR NAME:
Wendell Smith
TELEPHONE:
(818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/17/2021
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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