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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609050
Report Date: 10/09/2023
Date Signed: 10/23/2023 10:39:27 AM

Substantiated


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
10/05/2023 and conducted by Evaluator David Espana
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231005153010
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: 1DATE:
10/09/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Galina Tovmasian Business Office Manager TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not keep the resident's room clean & sanitary
Facility has mold
INVESTIGATION FINDINGS:
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**This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 10/09/2023 **
On 10/23/2023 at 8:45 am Licensing Program Analyst (LPA) David España conducted a subsequent complaint investigation at the above facility to address the following allegations due to facility closure of Terraza of Cheviot Hills, 197609050. LPA España met with Galina Tovmasian Business Office Manager and explained the purpose of this visit was to deliver findings for this P3 Terraza of Cheviot Hills, 197609050, 11-AS-20231005153010 complaint. Licensing Program Analyst (LPA) David España met Operations, Dan Gormley and S#2-S#3. Upon arrival at the facility, LPA España conducted a risk assessment at the facility entrance. Based on the assessment, the facility is clear of Covid-19 infection. At 12:46 pm the complaint visit was conducted with Operations, Dan Gormley. The investigation consisted of following: Interviews, record reviews, and LPA observations. LPA conducted a tour of the facility. LPA toured 2nd floor room #55; room #53; room #52; room #50; room #47; room #49 & room #54, 1st floor Dining room, kitchen, Lobby, Theatre room, Game room, room #26. LPA interviewed S#1-S#4 and R#1.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
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 6
Control Number 11-AS-20231005153010
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: 10/09/2023
NARRATIVE
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LPA requested and received the following resident files for R#1-#4: Resident Roster, Staff Schedule R#1-5 (Face sheet, Physician's Report, Admissions agreement, Pre-Appraisal, Needs and Services Plan.) Documents were received at the time of visit. Regarding the allegation: “Staff did not keep the resident's room clean & sanitary.” The investigation revealed the following: Regarding the allegation “Staff did not keep the resident's room clean & sanitary.” 1 out of 1 resident interviewed disagreed with the allegation and denied having any issues with room being clean & sanitary. 4 out of 4 staff (S#1-S#4) denied the allegation, S#1-S#4 denied not having provided a room clean & sanitary living conditions to residents. Interviews conducted with S#1-S#4, stated that the staff are required to provide a room clean & sanitary to all residents in care. S#1-S#4 stated that the residents are never denied a clean & sanitary room. The facility ensured that staff clean all rooms daily. During a facility tour on 10/09/2023 at 9:49 am, LPA observed the 2nd floor, room #55; room #53; room #52; room #50; room #47; room # 49 & room #54 and interviewed R#1 who stated they have never had problems with a room being clean & sanitary. Based on LPA’s interviews conducted, record reviews, observation, and LPA tour with S2 and S3 of the 2nd floor, room #55; room #53; room #52; room #50; room #47; room # 49 & room #54, 1st floor Dining room, kitchen, Lobby, Theatre room, Game room, room #26; LPA and S2 observed room#49 with a bed with box spring on the floor, with excessive dirt, improper maintenance of living quarters, window having mildew, an uninhabitable room/living situation. LPA with S2 observed two corrugated boxes on the floor near the resident bed with feces with foul smell of stool. LPA and S2 observed the resident’s carpet with feces and the bed fibers and textures of bed with feces. LPA and S2 observed brown discoloration which was feces as confirmed by S2. Regarding the allegation: “Facility has mold.” The investigation revealed the following: Regarding the allegation “Facility has mold.” 1 out of 1 resident interviewed agreed with the allegation the facility has mold. 4 out of 4 staff (S#1-S#4) denied the allegation, S#1-S#4 denied the facility has mold. Interviews conducted with S#1-S#4, communicated that the staff are required to clean any mold from resident(s) rooms. Interviews conducted with R#1 communicated there was mold in rooms. Based on LPA’s interviews conducted, record reviews, observation, and LPA tour with S2 and S3 of the 2nd floor, room #55; room #53; room #52; room #50; room #47; room # 49 & room #54, 1st floor Dining room, kitchen, Lobby, Theatre room, Game room, room #26; LPA and S2 observed windows having mildew/mold on the 2nd floor. Based on the interviews with staff and observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D. An exit interview was conducted, and a hard copy was provided with appeal rights to Galina Tovmasian Business Office Manager. See LIC 9099-D on the next page.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20231005153010
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2023
Section Cited
CCR
87303(a)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The administrator will create a plan to ensure future compliance to Title 22 Regulation 87303(a) Maintenance and Operation. Proof of correction will be submitted to the department via email at David.espana@dss.ca.gov.
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This requirement was not met as evidence by: observation of the 2nd floor, room #55; room #53; room #52; room #50; room 47; room # 49 & room #54 being in disrepair due to maintenace.
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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: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
10/05/2023 and conducted by Evaluator David Espana
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231005153010

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: 1DATE:
10/09/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Operations, Dan Gormley TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not provide sufficient notice of eviction.
Staff did not bill resident according to the resident's admisison agreement.
Staff left resident soiled in feces.
INVESTIGATION FINDINGS:
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On 10/09/2023 at 8:50 am Licensing Program Analyst (LPA) David España conducted unannounced initial 10-day visit to the facility and purpose of the complaint investigation of the allegations listed above were explained. Licensing Program Analyst (LPA) David España met Operations, Dan Gormley and S#2-S#3. Upon arrival at the facility, LPA España conducted a risk assessment at the facility entrance. Based on the assessment, the facility is clear of Covid-19 infection. Today’s complaint visit was conducted with Operations, Dan Gormley.

The investigation consisted of following: Interviews, record reviews, and LPA observations. LPA conducted a tour of the facility. LPA toured 2nd floor room #55; room #53; room #52; room #50; room #47; room # 49 & room #54, 1st floor Dining room, kitchen, Lobby, Theatre room, Game room, room #26. LPA interviewed S#1-S#4 and R#1.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20231005153010
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: 10/09/2023
NARRATIVE
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LPA requested and received the following resident files for R#1-#4: Resident Roster, Staff Schedule R#1-5 (Face sheet, Physician's Report, Admissions agreement, Pre-Appraisal, Needs and Services Plan.) Documents were received at the time of visit.
Regarding the allegation: “Staff did not provide sufficient notice of eviction.” The investigation revealed the following: Regarding the allegation “Staff did not provide sufficient notice of eviction.” 1 out of 1 resident interviewed disagreed with the allegation and denied having any issues with notice of eviction. 4 out of 4 staff (S#1-S4) denied the allegation, S#1-S#4 denied not providing notice of eviction to residents. Interviews conducted with S#1-S#4, communicated that the staff are required to provide notice of eviction to residents. Interviews conducted with R#1 communicated they have never had problems with staff and notices. As far as they know, the staff has always provided notices. Based on LPA’s interviews and observations could not concur with the above allegation.
Regarding the allegation: “Staff did not bill resident according to the resident's admission agreement.” The investigation revealed the following: Regarding the allegation “Staff did not bill resident according to the resident's admission agreement.” 1 out of 1 resident interviewed disagreed with the allegation and denied having any issues with billing and resident's admission agreement. 4 out of 4 staff (S#1-S#4) denied the allegation, S#1-S#4 denied not providing bill to resident according to the resident's admission agreement for residents. Interviews conducted with S#1-S#4, communicated that the staff are required to provide a bill to resident according to the resident's admission agreement. S#1-S#4 stated that the residents are never denied anything request for records. The facility ensures that staff is always aware on how to help residents with admission agreement questions. Interviews conducted with R#1 communicated they have never had problem with staff providing bills to resident according to the resident's admission agreement. Based on LPA’s interviews and observations could not concur with the above allegation.
Regarding the allegation: “Staff left resident soiled in feces.” The investigation revealed the following: Regarding the allegation “Staff left resident soiled in feces.” 1 out of 1 resident interviewed disagreed with the allegation and denied having any issues or knowing any Staff leaving any resident soiled in feces. 4 out of 4 staff (S#1-S#4) denied the allegation, S#1-S#4 denied leaving any resident soiled in their feces while in care. Interviews conducted with S#1-S#4, communicated that the staff are required to change resident and check every resident daily. Based on LPA’s interviews and observations could not concur with the above allegation.See LIC9009-C on the next page.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20231005153010
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: 10/09/2023
NARRATIVE
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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 hard copy was provided with appeal rights to Dan Gormley.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6