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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609050
Report Date: 04/14/2022
Date Signed: 04/14/2022 03:57:54 PM


Document Has Been Signed on 04/14/2022 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA



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: 38DATE:
04/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Doina "Stephanie" RaduTIME COMPLETED:
04:30 PM
NARRATIVE
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***This is a corrected copy of the LIC 809/809C/809D/LIC 421M that was created on 10/22/2021 during a subsequent case management visit.***

Licensing Program Analyst (LPA) Nicol Wesley conducted a case management visit and met with Administrator Stephanie Radu. The purpose for todays visit was discussed.

On 10/22/21 Licensing Program Analyst (LPA) Nicol Wesley initiated a subsequent case management visit and met with Executive Director Joey Alvarado to discuss the purpose for the visit.

On November 27, 2019 the department conducted an on site case management visit to investigate and gather additional information regarding the death of resident #1(R1) upon receiving an Unusual Incident Report(UIR/SIR) from the facility dated 10/22/2019. On 10/17/19 resident #1(R1) was hospitalized due to severe burn injuries caused by smoking cigarettes on the facility premises. On 10/19/19 R1's family informed Administrator Matan Rabinowitz-Burstyn that R1 passed away.

Department of Social Services, Community Care Licensing Division Investigations Branch Investigator Lorraine Patterson conducted an investigation and the investigation report conclusions were based on Los Angeles County Fire Department(LAFD) records, Hospital/Medical records, Los Angeles County Police Department(LAPD) communications records, Death certificate, and the facility file for R1.
A copy of the Los Angeles Fire Department (LAFD) report revealed on 10/17/2019, R1 was unaware their coat and wheelchair were on fire until the fire grew large. Documents obtained revealed that R1

Continued on LIC 809C.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/14/2022
NARRATIVE
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was on hospice care, had dementia, poor memory, mild cognitive impairment, and also visual and auditory impairments. Documentation further revealed R1 was mentally and physically unable to escape a fire danger. Investigator Lorraine Patterson conducted interviews as follows: Previous Facility Administrator, Matan Rabinowitz-Burstyn reported that R1 was alert and oriented and the facility had no concerns with R1's mental or physical ability to ambulate in their wheelchair unsupervised. Administrator Rabinowitz-Burstyn reported that R1 was a heavy smoker for years, and always did what they wanted regardless of what facility staff told them. Rabinowitz-Burstyn advised that resident #1 and their family were verbally informed that R1 could not sit and smoke cigarettes in front of the facility entrance where it was hugely labeled “No Smoking.” On 05/19/19, the facility staff provided R1 with a smoking reappraisal. R1 was approved to continue to smoke unsupervised in spite of, but not limited to facility staff knowing R1 often disregarded the facility’s rule, and also their own health and safety. Interviews and investigative leads also revealed the facility was aware R1 frequently exercised poor judgement particularly when it came to them smoking cigarettes. Based on sufficient evidence, neglect/lack of supervision and care resulting in a severe injury is deemed substantiated.

The following deficiencies are cited in accordance to California Code of Regulations, Title 22, Division 6, Chapter 8 is on the attached LIC 809D. An Immediate Civil Penalty will be issued today in the amount of $500.00 due to resident sustaining injury/illness while under the facility care.

Upon further review by the Program Office, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49, for a violation that resulted in the tragic, painful and preventable death of resident (R1).

LPA Wesley communicated with Regional VP of Operations Evelyn Mendez-Choy for her to notify the licensee(s) and other parties involved that the El Segundo District Office will be conducting a virtual Non Compliance Conference meeting during the week of 04/17/2022. Evelyn Mendez-Choy informed the LPA that she would make contact with LPM Angela Kendrick at 323 629 7815 to confirm the date and time of the meeting. A copy of the LIC 809/809C/809D/LIC 421M(Civil Penalty Assessment), and Appeal Rights were given during the exit interview.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2022 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: TERRAZA OF CHEVIOT HILLS
FACILITY NUMBER: 197609050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited

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Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Health and Safety Code section 1569.2(c). Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the
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residents physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
This requirement was not met as evidence by: On 10/17/2019 facility staff assisted R1 outside into the front
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Please provide the in-service training sign in sheet including the Topics that were reviewed to: CCLD/Attn: LPA Nicol Wesley by POC due date 04/29/22.

Type A
04/29/2022
Section Cited

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****CITATION CONTINUED****
entrance of the facility so they could get some air. Staff were aware that R1 had a medical condition and often exercised poor judgement and disregarded the facility house rules when it came to smoking cigarettes. R1 was in he non smoking area smoking and suffered 2nd
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and 3rd degree burns on approximately 40% of their body to include their upper right and lower back, burns to their entire chest and abdomen, and also soot and burns to their mouth. This posed an immediate health and safety risk. An immediate civil penalty in the amount of $500 will be issued on the LIC 421M form.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 04/14/2022 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: TERRAZA OF CHEVIOT HILLS
FACILITY NUMBER: 197609050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited

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Administrators Qualifications and duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply........
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(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement was not met as evidence by: exercised poor judgement when it came to smoking cigarettes and was approved to smoke unsupervised in spite of, but not limited to the facility staff knowing R1
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As of 07/01/2020, Administrator Matan Rabinowitz-Burstyn no longer works in the facility. Please provide the in-service training sign in sheet including the Topics reviewed to: CCLD/Attn: LPA Nicol Wesley by POC due date 04/29/22.
Type A
04/30/2022
Section Cited

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***CITATION CONTIUED****

often disregarded the facility’s house rule and their own health and safety. This posed an immediate health and safety risk to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 04/14/2022 03:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA


FACILITY NAME: TERRAZA OF CHEVIOT HILLS
FACILITY NUMBER: 197609050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2022
Section Cited

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Care of Persons with Dementia
Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually. This requirement was not met as evidence by: R1 was diagnosed with
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Dementia and did not have a current medical evaluation on file. The last Physician’s report for R1 was on 03/06/2015. This requirement was not met as evidence by: R1 was diagnosed with Dementia and did not have a current medical evaluation on file. The last
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In the future, the Licensee/Administrator will ensure that all residents diagnosed with dementia will have an annual medical assessment and a reappraisal done annually or if there is a change in condition. R1 no longer resides in the facility.
Type A
04/29/2022
Section Cited

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****CITATION CONTINUED****

Physician's report for R1 was dated 03/06/2015 which posed a health and safety risk to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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