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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609050
Report Date: 08/04/2020
Date Signed: 08/04/2020 03:46:56 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2020 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200204145957
FACILITY NAME:TERRAZA OF CHEVIOT HILLSFACILITY NUMBER:
197609050
ADMINISTRATOR:BURSTYN, MATANFACILITY TYPE:
740
ADDRESS:3340 SHELBY DRTELEPHONE:
(310) 837-9181
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:100CENSUS: 66DATE:
08/04/2020
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Greg BeckerTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff failed to seek timely emergency medical care for resident.
INVESTIGATION FINDINGS:
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LPA Angelica Rea conducted another visit to issue the final results of the investigation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint visit was conducted telephonically with Administrator, Greg Becker.

The department conducted an investigation regarding the allegation that staff failed to seek timely emergency medical care for resident #1. The investigation consisted of interview(s) with facility staff, review of resident #1 medical records, and interview(s) with medical staff. The investigation revealed that resident #1 was admitted to the hospital on 7/31/19 due to falling out of his bed, but returned to the facility on the same day. On 8/1/19, resident #1 was found on the floor at 6:30am, and was assessed by staff. Resident #1 was found to be alert during the assessment. Resident #1's family was notified on the same day. Resident #1 was later transported to the hospital. Resident #1 passed away on 8/4/19 at the hospital. Medical records and interviews with medical staff indicate that the primary cause of death was due to preexisting medical conditions. Medical records listed no suspected signs of abuse or neglect. The investigation did not reveal any evidence to support that staff failed to seek timely emergency medical care for resident #1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2020
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 28-AS-20200204145957
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: TERRAZA OF CHEVIOT HILLS
FACILITY NUMBER: 197609050
VISIT DATE: 08/04/2020
NARRATIVE
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Although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED. Appeal rights provided. Exit Interview conducted, and copy of report given.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020
LIC9099 (FAS) - (06/04)
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