197609050-11-3-2020-11-AS-EMAZ-BZWW39-20210409165534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609050
Report Date: 11/03/2020
Date Signed: 11/03/2020 03:34:16 PM

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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2020 and conducted by Evaluator Stephanie Cifuentes

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200410103913

FACILITY NAME:	TERRAZA OF CHEVIOT HILLS		FACILITY NUMBER:	197609050
ADMINISTRATOR:	BURSTYN, MATAN		FACILITY TYPE:	740
ADDRESS:	3340 SHELBY DR		TELEPHONE:	(310) 837-9181
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	100	CENSUS: 63	DATE:	11/03/2020
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Greg Becker-Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained multiple fractures while in care
Staff failed to administer resident's medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Greg Becker, the facilities Administrator.

The investigation consisted of the following:

On 4/13/2020 Licensing Program Manager (LPM) Eva Alvarez conducted a telephone interview with administrator Greg Becker and completed a video call tour of facility. LPM Alvarez requested and received the following information: Physicians report, admissions agreement, needs and services plan, case notes, medication log and emergency identification. On 8/4/2020 LPA Stephanie interviewed facility staff and on 8/14/2020 interviewed facility clients and witnesses. LPA requested and received the following additional documentation: Emergency identification for residents 2-residents 8, medication records for residents 1-resident 3. A review of the IB branch’s case report was conducted on 7/28/2020.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

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 4

Control Number 11-AS-20200410103913

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
MONTERY PARK, CA 91754

FACILITY NAME: TERRAZA OF CHEVIOT HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 11/03/2020

NARRATIVE

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Regarding the allegation: Resident sustained multiple fractures while in care

The investigation revealed the following:

Investigator Peter Zetruche from the investigations branch of Community Care Licensing conducted interviews with staff from this facility, facility clients, hospice staff, family members and hospital doctor. Medical records/reports, medications and pertinent personal records were reviewed and found there is no evidence to corroborate the allegation “Resident sustained multiple fractures while in care”.

Per interviews, there were no witnesses to fall and medication records indicate medications were administered as prescribed. Physicians report shows client as independent and did not label her as a fall risk, nor is there any documentation stating resident was a fall risk. There was no neglect suspected by hospital personnel. Coroner’s office reports show cause of death was accidental. The department was not able to find any evidence that there was a lack of care and supervision that resulted in residents’ multiple fractures.

Based on IB’s observation, interviews conducted, and records reviewed, 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(s) did or did not occur, therefore the allegation is unsubstantiated.

Cont on 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20200410103913

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
MONTERY PARK, CA 91754

FACILITY NAME: TERRAZA OF CHEVIOT HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 11/03/2020

NARRATIVE

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Regarding the allegation: Staff failed to administer resident’s medication as prescribed

The investigation revealed the following:

On 4/13/2020 LPM Alvarez conducted a video tour of facility grounds and collected facility files.

On 7/28/2020 and 9/2/2020 LPA Cifuentes reviewed facility records. LPA found that on 7/10/2020 and 7/18/2020 there were no initials on the medication administration records (MAR) for four of resident 2’s medications and five of resident 3’s medication. Upon further review of records from those dates it was found that the electronic medication administration record system had gone offline in the evenings. The glitch caused a failure to retain previous data recorded in the system, so none of the evening meds were recorded for any facility resident on 7/10/2020 or 7/18/2020. As the system does not allow staff to go back, there could be no correction made to the record. Facility has spoken with their vendor regarding the issue.

On 7/28/2020 LPA reviewed the medication administration record(MAR) for resident 1 (R1). Resident one takes four blood pressure medications. Per doctors orders they should not be administered if R1’s lood pressure is too low. eMar shows three of the four medications administered to resident despite doctors’ orders not to do so. LPA found no notes in electronic MAR as to why, although there are notes in a separate section that fourth blood pressure medication was not given due to low blood pressure. Per medical technicians, resident has the option to retake their blood pressure and if it is at a higher level they can then be administered the medications if they wish to take them. The electronic MAR does not allow staff to make a note when the blood pressure is retaken, and the medication is administered later.

Cont on 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20200410103913

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
MONTERY PARK, CA 91754

FACILITY NAME: TERRAZA OF CHEVIOT HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 11/03/2020

NARRATIVE

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On 8/14/2020 LPA interviewed 7 facility clients. LPA asked residents if their medications were being administered as prescribed. 5 out of 7 clients stated their medications are administered as prescribed. On 8/4/2020 LPA interviewed facilities medical technicians. Per Staff 1-Staff 3 medication system logs when a resident does not take a medication and a note is entered into the system. If a resident’s medication is dependent on their blood pressure it is the resident’s choice whether or not to wait and get their blood pressure checked later so that they may then take the medication.

On 6/16/2020 LPA interviewed 4 witnesses and asked if they had been told that residents’ medication was not being administered as prescribed. 3 or 4 witnesses stated they had no knowledge of incorrectly administered medications.

Based on LPA’s observation, interviews conducted, and records reviewed, 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(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of the report was emailed to Greg Becker, executive director.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 4