197601221-8-11-2023-31-AS-TAGD-CVLNJB-20230912103000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197601221
Report Date: 08/11/2023
Date Signed: 08/11/2023 03:25:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
06/21/2021 and conducted by Evaluator Tuesday Cabiness

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210621085541

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: 4	DATE:	08/11/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Bozena Kozbial		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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1. Staff yell at resident
2. Staff make inappropriate comments towards resident
3. Resident denied phone calls
4. Staff do not provide residents with activities
5. Staff did not safeguard residents personal belongings
6. Residents are left unattended
7. Resident sustained injury while in care
8.Staff do not provide adequate food service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a subsequent visit to deliver the final findings of the allegation mentioned above. LPA met with Administrator Bozena Kozbial and the following was determined:

Allegation # 1: Staff yell at resident: Concerns were expressed “Staff yell at residents. On June 30, 2021, and April 28, 2023, from various times, 10am to 4pm, LPA conducted interviews with the complainant, staff, and residents. On both days, according to interviews, residents have never witnessed staff yell or scream at them; nor have they witnessed staff yell or scream at other residents. Residents reported they were happy at the facility, and staff were respectful and caring. Therefore, based on interviews, LPA could not prove “Staff yell resident”, and at this time, the allegation is UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023

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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Control Number 31-AS-20210621085541

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARBLE TERRACE	FACILITY NUMBER: 197601221
	VISIT DATE: 08/11/2023

NARRATIVE

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Allegation # 2: Staff made an inappropriate comment to the resident; Concerns were expressed, “Staff made an inappropriate comment to the resident. On June 30, 2021, and April 28, 2023, from various times, from 10am to 4pm, LPA conducted interviews with the complainant, staff, and residents. From information obtained, LPA determined that, there were no witnesses, who heard staff make any inappropriate comment to any residents at the facility. Residents reported to LPA, the have never heard staff be inappropriate to residents while in care, and reported, that staff are respectful and caring. Therefore, based on interviews, the allegation is deemed UNSUBSTANTIATED at this time.

Allegation # 3: Resident denied phone calls: Concerns were expressed that “resident was denied phone calls”. On June 30, 2021, and April 28, 2023, from various times, from 10am to 4pm, LPA conducted interviews with the complainant, staff, and residents. It was reported that resident #1 (R1) was denied making long distance phone calls and staff was listening to R1’s personal phone calls. Interviews reported that all residents are allowed to make local and long-distance, and residents always have access to the facility phone. Residents reported to LPA, that they rarely use the facility phone, because they have personal cellphone. Residents also stated, they have privacy, and never observed staff listening to their phone calls. Administrator and all staff also denied interfering with R1’s personal call. Therefore, based on interviews, the allegation is Unsubstantiated at this time.

Allegation # 4 Staff do not provide residents with activities: Concerns were express, that “Staff do not provide residents with activities. On June 30, 2021, and April 28, 2023, from various times, from 10am to 4pm, LPA conducted interviews with the complainant staff, and residents. The Administrator stated that they do offer activities to the residents, however the residents in care enjoy their privacy and are not very active. The Administrator stated that for the most part, residents deny certain activities, but they do engage in conversations, games, and TV watching in the common rooms with staff. LPA conducted interviews with residents who were able to communicate, and they stated that they do not care much for games or activities. They enjoy watching TV, talking to family, and enjoy their privacy, and for the most part, keep to themselves. Based on interviews, the allegation mentioned above is Unsubstantiated at this time.

Allegation # 5: Staff did not safeguard residents’ personal belongings: Concerns were expressed, that “Staff did not safeguard resident’s personal belongings. On June 30, 2021, and April 28, 2023, from various times, from 10am to 4pm, LPA conducted interviews with staff, residents, and witness. LPA received documentation.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20210621085541

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARBLE TERRACE	FACILITY NUMBER: 197601221
	VISIT DATE: 08/11/2023

NARRATIVE

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from the facility, that during the day of resident #1 (R1) moving out of the facility, R1 signed a document, showing which items were being given to her, and what R1 was leaving with. It was also reported to LPA, that R1’s family member, had possession of R1 property before she moved into the facility, and the family member also moved R1’s property into a storage unit. R1 was not aware of what was in the storage, and R1 was not aware of what property was given to R1 when R1 moved into the facility. Facility staff reported to LPA, for a period of time, the facility maintained R1’s personal property in their garage, but after a period of time, the family member removed the property for R1. LPA determined, there is no accurate documentation of what property R1 had. Also, LPA observed on the day R1 moving out of the facility, R1’s property was being moved out with R1’s family friend. Therefore, based on interviews, and observation, the allegation is Unsubstantiated at this time.
Allegation # 6: Staff do not provide adequate food service: Concerns were expressed that “Staff do not provide adequate food service”. On June 30, 2021, and April 28, 2023, from various times, from 10am to 4pm, LPA conducted interviews with staff, residents, and conducted a physical plant inspection. During the visit on April 28, 2023, LPA toured the facility and observed an abundance of fresh fruits and vegetable, and an adequate supply of perishables. Residents reported to LPA that the food is good, and there are no issues or concerns with the quality. Also, during the visit, LPA observed the lunch that was served, and it observed to be healthy and fresh. There was also a variety of food for residents. Therefore, based on interviews and observations, the allegation is Unsubstantiated at this time.
Allegation # 7: Residents are left unattended: Concerns were expressed that “Residents are left unattended”. On June 30, 2021, and April 28, 2023, from various times, between 10am to 4pm, LPA conducted interviews with staff, and residents. LPA conducted interviews with staff and residents. Interviews of staff denied leaving any resident unattended at the facility at any given time. Interviews with residents indicated that they have not experienced and/or observed staff leaving them unattended at any time. Based on interviews, the allegation is Unsubstantiated at this time.
Allegation # 8: Resident sustained injury while care. Concerns were expressed that “Resident sustained injury while in care. On June 30, 2021, and April 28, 2023, from various times, between 10am to 4pm, LPA conducted interviews with the complainant, staff and residents. Information obtained, revealed resident # 1 (R1) was admitted to the facility with already an injury to the leg, and was receiving home health services to treat the wound on the leg. Interviews also revealed, there was no witnesses of R1 being injured, or that staff injured R1. Therefore, based on interviews, there is insufficient evidence that R1 sustained an injury while in care, and the allegation is Unsubstantiated at this time.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

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