197609050-3-8-2022-11-AS-AJKK-CDQVKQ-20220422163044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609050
Report Date: 03/08/2022
Date Signed: 03/08/2022 02:49:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2022 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220222134538

FACILITY NAME:	TERRAZA OF CHEVIOT HILLS		FACILITY NUMBER:	197609050
ADMINISTRATOR:	JOEY ALVARADO		FACILITY TYPE:	740
ADDRESS:	3340 SHELBY DR		TELEPHONE:	(310) 837-9181
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	100	CENSUS: 44	DATE:	03/08/2022
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Administrator, Doina "Stephanie" Radu		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not provide nutritious meals for the residents
Staff do not have planned activities for the residents
Staff are unable to properly maintain the facility
Residents do not have linen service while in care
Staff do not provide the residents with ample toiletries
Residents do not have laundry services while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 03/08/2022 Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation at the above facility to address the following allegations. LPA Agard was met with Administrator, Doina "Stephanie" Radu and explained the purpose of the visit was to gather information regarding this complaint.

The investigation consisted of the following: On 02/25/2022, LPA conducted a 10-day visit and met with Administrator. LPA completed interviews and requested copies of facility records. LPA requested: Staff and Client roster. On 02/28/2022, LPA conducted additional interviews and requested additional documents.

On 03/08/2022, LPA Agard delivered findings.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

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 5

Control Number 11-AS-20220222134538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 03/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation: Staff do not provide nutritious meals for the residents. It’s being alleged the facility is not providing this service. “There is no nutritionist, the food is inedible lowest cost animal fodder provided as meals.” The investigation revealed the following: 7 out of 7 staff interviewed generally denied the allegation to be true. S1 states, “we do not have a full-time nutritionist. Residents get 3 meals per day. They have 6 to 7 alternative meals in addition to the regular meal’s menu. There is a lot to choose from.” S2 states, “we have a weekly print out of what’s being served. I see all the major food groups. There is also always an alternative menu available.” S6 states, “the Dietary Service Director works with the kitchen staff. If we had complaints, we would have them sit down together. Generally, we include all food groups in our meals and is based on assessments of the resident. The resident has an alternative menu. When I’m there, I ask just to see that it can be produced. I do test them.” LPA observed a variety of fruits and beverages available for snack. LPA observed a balance breakfast and lunch that consisted of items from the major food groups.

During interviews with the residents the following was revealed. 4 of the 6 denied the allegation to be true. 1 resident was unable to interview. R1 was unavailable for an interview. R2 states, “the food here… you have to be here to understand. I don’t like the way they cook. They don’t have a professional cook here. They have only 2 cooks that are good. When it comes to the food it sucks. I barely eat here. They provide overcooked veggies. I don’t like the way the food looks. 3 times out of the week I might eat pretty good, the other days the food goes in the trash. That’s the only problem I have here. Yes, I could say I want something else.” R3 and R4 both denied the allegation, “we have good meals here.” “I can’t have a lot of salt, but they have gotten better. They do have alternative menus. I have been here for many years so I can definitely say yes they will give you something else if you ask for it.” R6 states, “well I have to say yes, if you don’t like what they serve you can request something else. I’m not a fish lover so when I request, they seem to be fine and don’t really give me a problem. In fact, I’ve gained weight since I’ve been here. The food is not bad.”
Regarding the allegation: Staff do not have planned activities for the residents. It’s being alleged the facility is not providing this service. “There is no activity director with a degree to assist the elderly and no exercise director with a degree in safety for the geriatric.” The investigation revealed the following: 7 out of 7 staff interviewed generally denied the allegation to be true. S1 states, “we have an activity director; they are so involved. We have a calendar and newsletter. The activities are offered but not enforced. Most of the resident’s decline.” S2 states, “we do have planned activities. I try to switch it up. The residents are provided with an activities calendar.” S3 states, “I see them participating in activities but its only 5 or 4 people that are there. They play bingo, exercise, celebrate parties for birthdays and other special days, and events for the
Continued on 9099C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20220222134538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 03/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

holidays.” S4 states, “yes, they have planned activities. On the weekends they go on outings. They have movie nights.”

During interviews with the residents the following was revealed. 4 of the 6 generally denied the allegation to be true. 1 resident was unable to interview. R1 was unavailable for an interview. R2 states, “there used to be a lot of activities in the past but now it’s a nursing home, not an assisted living. I don’t know the new activities director.” R4 states, “they do have celebrations for your birthday, exercise groups and other things to do but they need more outings.” R5 states, “Yes, absolutely. I am doing therapy during that time so that’s why I don’t participate, but yes, they have them. I receive the calendar with activities monthly and daily. R6 states, “yes, that’s not right. They have game night, movies, it’s there, you have to make yourself available. They will even take you shopping if you want to go shopping. I disagree with that. If you sit in your room all day of course you will miss out.”

Regarding the allegation: Staff are unable to properly maintain the facility. It’s being alleged the facility is not providing this service. “There is one overworked maid for a 90-bed facility and no licensed electrician, plumber or otherwise licensed full-time building technician on payroll.” The investigation revealed the following: 7 out of 7 staff interviewed generally denied the allegation to be true. S1 states, “I have 2 housekeepers. We all help, that includes me. There is at least one person that comes every day. When one is off there is at least one per day. The gardener comes once a week. We tour the outside grounds. I have a maintenance director on a leave of absence, but we have a contracted service for a maintenance worker to come in as needed.” S2 states, “there are 2 housekeepers. They do a good job cleaning.” S3 states, “I think we do a good job cleaning. No one ever complains.” S6 states, “currently, we have a contracted maintenance worker that comes in at night. He is an independent contractor. He does not have specific hours. We provide him with a list. I email him needs for the facility.” S7 states, “No, that’s okay I don’t need help cleaning. I cleaned here as much as I can. 5 rooms each are clean per day between myself and the other cleaning person. Most of the rooms are vacant. There are about 20 rooms that are being used.”

During interviews with the residents the following was revealed. 5 of the 6 generally denied the allegation to be true. 1 resident was unable to interview. R1 was unavailable for an interview. R2 states, “this is the cleanest facility I’ve ever been in and I’ve been in 4 or 5.” R3 states, “yes, they maintain the facility well, but they need more housekeeping staff. At least 3 or 4. 2 housekeepers are not enough. There used to be 4 but
Continued on 9099C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20220222134538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 03/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

they have been cutting back.” R4 states, “they do a good job with that. They do clean well. They keep the area clean. It’s fine. Maintenance helps fix things.” R6 states, “there is no problem there.”

Regarding the allegation: Residents do not have linen service while in care. It’s being alleged the facility is not providing this service. “There is no linen service.” The investigation revealed the following: 7 out of 7 staff interviewed generally denied the allegation to be true. S1 states, “we have 2 industrial size washers. The two housekeepers do laundry and sometimes the staff if need be but there is plenty of linen here. We ask the residents to have at least 3 pairs of sheets. S2 states, “the housekeepers are always washing laundry. We do ask the residents to have extra sheets so they can rotate them. Laundry is done once per week.” S3 states, “I wash their clothing, their sheets, clean their apartments. We do not iron.” S4 states, “Housekeeping washes laundry, clothing, and bedding. They don’t iron. S7 states, “I provide linen service, wash their clothes, clean their room. It’s easy now because there isn’t a lot of residents.”

During interviews with the residents the following was revealed. 5 of the 6 generally denied the allegation to be true. 1 resident was unable to interview. R1 was unavailable for an interview. R2 states, Yes, they wash my bedding. I don’t have any problem with that.” R3, R4 & R5 denied the allegation, “yes, they provide me with linen and laundry services.” R6 states, “oh yes, they have a gal that comes to me every Saturday and does the laundry and linen.”

Regarding the allegation: Staff do not provide the residents with ample toiletries. It’s being alleged the facility is not providing this, which they are supposed to. “Refusal to provide ample toilet paper or soap.” The investigation revealed the following: 7 out of 7 staff interviewed generally denied the allegation to be true. S1 states, “no one has complained that they don’t have toiletries. No one approached me. Most of the residents provide their own toiletries. We don’t really provide those things. The families provide or the residents. We give 2 rolls of toilet paper per week on their house keeping day.” S2 states, “The residents provide their own soaps and toothpastes for themselves. If the resident is able to be on their own, I even take them to the store. For the residents that can’t, the families provide, and for the ones that don’t have family, they have nurses aid that provide them with supplies. Toilet paper is not really withheld, its more evenly distributed.” S3 states, “we don’t provide soap or toothpaste. Toilet paper, yes.”

Continued on 9099C

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20220222134538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 03/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During interviews with the residents the following was revealed. 5 of the 6 generally denied the allegation to be true. 1 resident was unable to interview. R1 was unavailable for an interview. All residents interviewed, confirmed they or their family is solely responsible for providing personal care items. R2 states, “I buy my own. I don’t know about the other people. I buy my own soap, toothpaste, cologne.” R3, R4, R5 and R6 all state, “yes, we buy our own or provide their own.” All resident confirmed receiving toilet paper. 2 of 6 residents generally agree the amount of toilet paper given isn’t ample in supply.

Regarding the allegation: Residents do not have laundry services while in care. It’s being alleged the facility is not providing this service. “No ironing is provided with laundry service as mandated.” The investigation revealed the following: 7 out of 7 staff interviewed generally denied the allegation to be true. S1 states, “We wash the residents clothing once per week. If they want additional, it’s a la carte. S2 states, “when they take the linen, they take the laundry. We ask that the residents have a hamper with their name. We label everything. S3 states, “I wash their clothing, their sheets, clean their apartments. We do not iron.” S4 states, “housekeeping washes laundry, clothing and bedding. They don’t iron.” S7 states, “I provide linen service, wash their clothes, clean their room. It’s easy now because there isn’t a lot of residents. We are not supposed to iron.”

During interviews with the residents the following was revealed. 5 of the 6 generally denied the allegation to be true. 1 resident was unable to interview. R1 was unavailable for an interview. R2 states, “Yes, they wash my clothing. Everything here is great.” R3 states, Oh Yes, they wash our linen and clothing once per week. R4 states, “yes, they do provide us with that.” R6 states, “Oh yes, they have a gal that comes to me every Saturday and does the laundry and linen. I want to stress I’m very happy here, the people are very helpful here. This is as close to home as it can get.”

LPA reviewed the following records: A copy of facility’s alternative menu. According to the menu, selected items are offered as an alternative to the meal of the day. LPA reviewed a copy of the Activities Director job description, and a copy of the activities calendar which shows activities every day of the month. A copy of the housekeeping/ toilet paper schedule, which shows the days residents receive their replenishment of toiletries and cleaning services. A copy of an invoice billed for maintenance services. An Admission agreement that states laundry services are included in basic services. The laundering services does not offer any ironing services. Any additional laundry will be done for an additional fee. Per the admission agreement, activities will be offered. There may be an additional charge for some activities and events.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of the report was given.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5