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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609050
Report Date: 10/22/2021
Date Signed: 10/22/2021 02:20:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:TERRAZA OF CHEVIOT HILLSFACILITY NUMBER:
197609050
ADMINISTRATOR:JOEY ALVARADOFACILITY TYPE:
740
ADDRESS:3340 SHELBY DRTELEPHONE:
(310) 837-9181
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:100CENSUS: 52DATE:
10/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Joey Alvarado TIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nicol Wesley initiated a subsequent case management visit and met with Executive Director Joey Alvarado to discuss the purpose for todays visit.

On November 27, 2019 the department conducted an on site case management visit to investigate and gather additional information regarding the death of resident #1(R1) upon receiving an Unusual Incident Report(UIR/SIR) from the facility dated 10/22/2019.

On 10/17/19 resident #1(R1) was hospitalized due to severe burn injuries caused by smoking cigarettes on the facility premises. On 10/19/19 R1's family informed Administrator Matan Rabinowitz-Burstyn that R1 passed away.

Department of Social Services, Community Care Licensing Division Investigations Branch Investigator Lorraine Patterson conducted an investigation and the investigation report conclusions were based on Los Angeles County Fire Department(LAFD) records, Hospitial/Medical records, Los Angeles County Police Department(LAPD) communications records, Death certificate, and the facility file for R1.
A copy of the Los Angeles Fire Department (LAFD) report revealed on 10/17/2019, R1 was unaware their coat and wheelchair were on fire until the fire grew large. Documents obtained revealed that R1 was on hospice care, had dementia, poor memory, mild cognitive impairment, and also visual and auditory impairments. Documentation further revealed R1 was mentally and physically unable to escape a fire danger. Investigator Lorraine Patterson conducted interviews as follows: Previous Facility Administrator, Matan Rabinowitz-Burstyn reported that R1 was alert and oriented and the facility had no Continued on LIC 809C.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: TERRAZA OF CHEVIOT HILLS
FACILITY NUMBER: 197609050
VISIT DATE: 10/22/2021
NARRATIVE
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concerns with R1's mental or physical ability to ambulate in their wheelchair unsupervised. Administrator Rabinowitz-Burstyn reported that R1 was a heavy smoker for years, and always did what they wanted regardless of what facility staff told them. Rabinowitz-Burstyn advised that resident #1 and their family were verbally informed that R1 could not sit and smoke cigarettes in front of the facility entrance where it was hugely labeled “No Smoking.” On 05/19/19, the facility staff provided R1 with a smoking reappraisal. R1 was approved to continue to smoke unsupervised in spite of, but not limited to facility staff knowing R1 often disregarded the facility’s rule, and also their own health and safety. Interviews and investigative leads also revealed the facility was aware R1 frequently exercised poor judgement particularly when it came to them smoking cigarettes. Based on sufficient evidence, neglect/lack of supervision and care resulting in a severe injury is deemed substantiated.

The following deficiencies are cited in accordance to California Code of Regulations, Title 22, Division 6, Chapter 8 is on the attached LIC 9099D.

An Immediate Civil Penalty will be issued today in the amount of $500.00 due to resident sustaining injury/illness while under the facility care.

Upon further review by the Program Office, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49, for a violation that resulted in the tragic, painful and preventable death of resident (R1).

LPA Wesley informed the Executive Director Administrator to advise the licensee(s) that the El Segundo District Office will be contacting the facility to schedule a Non Compliance Conference meeting on a later date. .

A copy of the LIC 9099/9099C/9099D/LIC 421M(Civil Penalty Assessment), and Appeal Rights were given during the exit interview.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: TERRAZA OF CHEVIOT HILLS
FACILITY NUMBER: 197609050
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited

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Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights. (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. OR/AND (3)To be free from punishment, humiliation, intimidation,
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abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidence by: On 10/17/2019 facility staff assisted R1 outside into the front entrance of the facility
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Provide the in-service training sign in sheet including the Topics reviewed to: CCLD/Attn: LPA Nicol Wesley by POC due date 11/05/21.

Type A
10/22/2021
Section Cited

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***CITATION CONTINUED***
so they could get some air. Staff were aware that R1 had a medical condition and often exercised poor judgement and disregarded the facility house rules when it came to smoking cigarettes. R1 was in he non smoking area smoking and suffered 2nd and 3rd degree burns on approximately 40%
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of their body to include their upper right and lower back, burns to their entire chest and abdomen, and also soot and burns to their mouth. This posed an immediate health and safety risk. An immediate civil penalty in the amount of $500 will be issued on the LIC 421M form.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: TERRAZA OF CHEVIOT HILLS
FACILITY NUMBER: 197609050
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited

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Administrators Qualifications and duties
All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient
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number of hours to permit adequate attention to the management and administration of the facility as specified in this section When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility
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 As of 07/01/2020, Administrator Matan Rabinowitz-Burstyn no longer works in the facility Provide the in-service training sign in sheet including the Topics reviewed to: CCLD/Attn: LPA Nicol Wesley by POC due date 11/05/21.



Type A
10/22/2021
Section Cited

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***CITATION CONTINUED***
as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities...The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7).... This requirement was not met as evidence by: The Administrator
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and facility staff were aware that R1 exercised poor judgement when it came to smoking cigarettes and was approved to smoke unsupervised in spite of, but not limited to the facility staff knowing R1 often disregarded the facility’s house rule and their own health and safety. This posed an immediate health and safety risk to persons in care.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: TERRAZA OF CHEVIOT HILLS
FACILITY NUMBER: 197609050
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2021
Section Cited

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Care of Persons with Dementia
Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually. This requirement was not met as evidence by: R1 was diagnosed with Dementia and
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did not have a current medical evaluation on file. The last Physician’s report for R1 was on 03/06/2015. This requirement was not met as evidence by: R1 was diagnosed with Dementia and did not have a current medical evaluation on file. The last Physician’s report
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In the future, the Licensee/Administrator will ensure that all residents diagnosed with dementia will have an annual medical assessment and a reappraisal done annually or if there is a change in condition. R1 no longer resides in the facility.

Type A
11/05/2021
Section Cited

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***CITATION CONTINUED***

for R1 was on 03/06/2015 which posed a health and safety risk to persons in care.

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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Nicol WesleyTELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5