197609050-9-6-2023-11-AS-MVAO-CVLUMZ-20230912154309

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609050
Report Date: 09/06/2023
Date Signed: 09/06/2023 02:07:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
11/19/2021 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211119160547

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: 20	DATE:	09/06/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	A3: Allen "Chad" Boeddeker, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced subsequent visit to the facility and was greeted by the new Administrator (A3: Allen "Chad" Boeddecker). LPA/RA Ceniceros conducted a risk assessment prior to entering facility. A1 informed LPA/RA that the facility has no COVID cases nor do the residents or staff have symptoms. The purpose for today’s visit is to conduct a 2nd subsequent visit to deliver the findings pertaining to the above-mentioned allegation.

A 24-Hour visit was conducted by LPA Troy Agard on 11/22/21 who was met by the Acting Administrator (A2: Doina "Stephanie" Radu); as Administrator (A1: Joey Alvarado) was unavailable. A subsequent visit was conducted by LPA Troy Agard on 03/15/22 who was then met by Administrator (A2: Doina "Stephanie" Radu); as the Administrator (A1: Joey Alvarado) was unavailable at the time of this visit.

During today’s visit, LPA/RA Ceniceros interviewed the new Administrator (A3: Allen “Chad” Boeddeker)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20211119160547

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA OF CHEVIOT HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 09/06/2023

NARRATIVE

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and four (4) Staff Members (S1-S4). LPA/RA Ceniceros observed the residents during morning activities and interviewed three (3) Residents (R2-R3). Resident #1 was not interviewed during the 24-hour visit due to hospitalization on 11/17/21; and during the 1st subsequent visit, Resident #1 moved out on 12/01/21; and during the 2nd subsequent visit, Resident #1 had passed away in December 2021. LPA/RA interviewed (via landline) Witness #1 (Resident #1's Power of Attorney). LPA/RA Ceniceros reviewed copies of the following documents: Admission Agreement (01/25/16), Identification and Emergency Information, Appraisal/Needs and Services Plan, Physician’s Report (dated 06/28/21), Medication Administration Record (November 2021), Unusual Incident Report (dated 11/17/21), Resident Appraisal (dated 12/30/20), Resident Assessment (dated 09/06/23), Kaiser Home Health Notes (01/28/21 thru 06/24/21, Facility Narrative Charting (from 03/04/20 thru 11/17/21), and facility staff & resident rosters.

Regarding Allegation #1: this investigation revealed that Resident #1 was receiving home health care thru Kaiser Home Health Agency, effective 03/04/20 for wound care. On 11/17/21, Resident #1 was hospitalized at Kaiser Hospital for a Stage #3/Unstageable wounds. Interviews conducted of facility staff, four of the four corroborated that Kaiser Home Health was providing the wound care for Resident #1 twice (2x) a week. Resident Aides would reposition Resident #1 and would advise the Med Techs of the resident's change of condition that was documented in the Facility’s Narrative Charting (from 03/04/20 thru 11/17/21) and reported to the (former) Director of Nursing. Resident Aides would not conduct wound care changes due to the Kaiser Home Health nurses (LVN/RN) visiting Resident #1 would care for the resident's wounds. Facility staff confirmed received training on the topic of activities of daily living. On 11/17/21, Witness #2 (W2: Licensee’s Regional Nurse) observed the wound and detected an odor with drainage and the wound edges were red. Witness #2 determined that Resident #1 required to be evaluated by a MD and requested facility staff to have the resident transported (non-emergency) to Kaiser Hospital (via ambulance). An interview conducted of Witness #1 corroborated that Kaiser Home Health care services were not communicating to (former) Resident #1’s power of attorney; however, they were aware of the resident’s wound care being provided by an outside agency (Kaiser Home Health) based on their communication with the facility. Interviews conducted of the residents, three of the three corroborated that the facility provides quality care to the residents and they are meeting their activities of daily living. A review of the facility staff in-service training records on the topic of "Providing Best Quality Care Service & Experience to the Residents" was conducted on 11/01/22.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20211119160547

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA OF CHEVIOT HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 09/06/2023

NARRATIVE

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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 of NEGLECT/LACK OF SUPERVISION: Resident sustained multiple pressure injuries while in care is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the new Administrator (A3: Allen “Chad” Boeddecker).

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC9099 (FAS) - (06/04)

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