197609050-3-1-2021-11-AS-EMAZ-C3EUUK-20210527155341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609050
Report Date: 02/22/2021
Date Signed: 03/01/2021 08:19:48 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
05/05/2020 and conducted by Evaluator Susan Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200505151703

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: 58	DATE:	02/22/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Dana Anderson		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility did not issue full refund

INVESTIGATION FINDINGS:

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On 2/22/20, Licensing Program Analyst (LPA)/Susan Campos, initiated a subsequent complaint investigation visit for the allegation: Facility did not issue full refund. 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 Dana Anderson, Administraor. The investigation consisted of the following: LPA conducted a telephone interview and video call with (2) staff members and (7) residents. In addition, a telephone/video inspection, of the facilities’ physical plant and food supply for health and safety. Areas covered, in the teleconference, included: common areas: reception area and front door, dining room, kitchen, and food supply. In addition, reviewed the following documents: R1’s Admission Agreement, refund correspondence documents, copy of R1’s pet deposit refund check and the refund check delivery confirmation document.

Continued on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

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-20200505151703

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: 02/22/2021

NARRATIVE

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Allegations: Facility did not issue full refund

The investigation revealed, per LPA interviews, with staff, R1’s family member, and also review of documents, that the Terraza of Cheviot Hills facility did not issue R1’s family a full refund.

As part of the investigation, R1’s family member, provided the LPA with copies of email correspondence, between R1’s family, and S2, detailing the timeline of R1’s move out of items, from private room, and also the refund check correspondence between the facility staff S2 and R1’s family. R1’s family, moved out R1’s personal items, from facility room, on 11/23/19, and notified, previous Administrator per email, on 11/25/20. In addition, R1’s family notified S2, that the refund check received on 1/7/20, past 15 day deadline stated in admission agreement, did not include the Pet Admission Refund amount of $500.

S2 informed the family, per email dated 1/7/20, that would look into why the $500 was not processed. R1’s family sent S2 three additional emails, inquiring the status of the $500 check dated, 1/21/20, 1/24/20, 2/26/20, and also R1’s family inquired by telephone on 3/2/20, requesting S2, a status of refund check. Per emails, reviewed by LPA, S2 stated that was working on processing the refund check; however, the $500 refund was never mailed to R1’s family, and S2 did not respond to R1’s family request for update information.

On 5/8/20, LPA interviewed S2, and was informed by S2, that did not recall the status of R1’s refund check, and would have to check records and contact headquarters, to obtain information, regarding status of $500 refund check. In addition, S1 contacted headquarters on 5/8/20 and 5/11/20, to obtain the status of R1’s $500 refund check. On 5/11/20, S1 contacted LPA, and informed LPA, that the $500 refund check, was processed on 5/11/20, and overnight delivered to R1’s family. LPA contacted R1’s family, and obtained confirmation, that they received $500 refund check on 5/12/20.

On 5/12/20, LPA confirmed that R1’s family member, received two refund checks, on 1/7/20 and 5/12/20, that were past the 15 day refund requirement listed in admission agreement.

Based on information gathered, LPA did find sufficient evidence to support allegation

"Facility did not issue full refund".

Based on LPA observations and interviews which were conducted record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200505151703

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/22/2021 Section Cited CCR 87507(g)(3)(c)(1)	1 2 3 4 5 6 7	87507 Admission Agreements (1) If a licensee charges a preadmission fee, the licensee must provide the applicant or his or her representative with a written general statement describing all costs associated with the preadmission fee charges and stating that the preadmission fee is refundable, and describing conditions for the refund.` This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide LPA, per fax, facility procedures for resident refunds. Facility refund procedures will be faxed to DSSCCL fax number (323) 981-1781 POC Due Date is 3/1/2021
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee failed to ensure that R1's family member recieved refund per facility admission agreement deadline, which posed a potential health risk to residents in care.	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	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

LIC9099 (FAS) - (06/04)

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