<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609050
Report Date: 08/31/2022
Date Signed: 09/01/2022 11:24:34 AM

Document Has Been Signed on 09/01/2022 11:24 AM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:TERRAZA OF CHEVIOT HILLSFACILITY NUMBER:
197609050
ADMINISTRATOR:DOINA STEPHANIE RADUFACILITY TYPE:
740
ADDRESS:3340 SHELBY DRTELEPHONE:
(310) 837-9181
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY: 100CENSUS: DATE:
08/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:ROBIN CULVERTIME COMPLETED:
04:00 PM
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
On 8/31/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit observed during an unrelated complaint investigation.

LPA observed the following deficiency:
The facility did not report a positive Covid-19 case within 24 hours to CCLD.

California Code of Regulations, Title 22 Division (6) and Chapter (8) is being cited on the attached LIC9099-D.

Exit interview conducted, copy of the report and appeal rights were given to Administrator Robin Culver.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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 2
Document Has Been Signed on 09/01/2022 11:24 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 08/31/2022 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA OF CHEVIOT HILLS
FACILITY NUMBER: 197609050

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2022
Section Cited
CCR
87211(a)(2)

1
2
3
4
5
6
7
87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
1
2
3
4
5
6
7
The administrator shall ensure that all Covid-19 cases are reported to CCLD in a timely manner. The administrator shall submit an incident report about the positive Covid-19 case by the POC due date. The administrator shall provide an in-service training about the reporting requirements covered in this section of Title 22.
8
9
10
11
12
13
14
Based on LPA's review of records and interviews with the administrator and the facility nurse, one resident was tested positive with Covid-19 on 8/16/2022. This case was not reported to CCLD until LPA learned about the case during today's visit. This poses an immediate health, safety and/or personal rights risk to residents in case. .
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2