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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609050
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:33:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:TERRAZA OF CHEVIOT HILLSFACILITY NUMBER:
197609050
ADMINISTRATOR:JOEY ALVARADOFACILITY TYPE:
740
ADDRESS:3340 SHELBY DRTELEPHONE:
(310) 837-9181
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:100CENSUS: 53DATE:
11/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Doina "Stephanie" Radu, Acting AdministratorTIME COMPLETED:
03:00 PM
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On 11/29/2021 at 09:50 am, Licensing Program Analyst (LPA) Troy Agard conducted an unannounced case management incident visit. LPA was met by facility Administrator, and the purpose of the visit was explained.

The case management consisted of the following:


Physical tour of facility and residents’ room, review of resident records, photography of fire damage and wellness check of resident involved in incident on 11/22/2021.

An exit interview was conducted, and a copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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