197609050-10-19-2021-11-AS-AJKK-C89REG-20211029125727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609050
Report Date: 10/19/2021
Date Signed: 10/19/2021 05:41:55 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2021 and conducted by Evaluator Troy Agard

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210602160124

FACILITY NAME:	TERRAZA OF CHEVIOT HILLS		FACILITY NUMBER:	197609050
ADMINISTRATOR:	GREG BECKER		FACILITY TYPE:	740
ADDRESS:	3340 SHELBY DR		TELEPHONE:	(310) 837-9181
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	100	CENSUS: 54	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Adminstrator, Joey Alvarado		TIME COMPLETED:	03:17 PM

ALLEGATION(S):

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Facility has bed bugs.

INVESTIGATION FINDINGS:

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On 10/19/2021 Licensing Program Analyst (LPA) Troy Agard initiated a complaint investigation at the above facility to address the following allegation. LPA Agard was met with Administrator, Joey Alvarado and explained the purpose of the visit was to gather information regarding this complaint.

The investigation consisted of the following: LPA Agard toured the facility, conducted interviews with staff, residents, a resident’s responsible party and reviewed records.

On 10/19/2021 LPA Agard delivered findings.

Regarding the allegation: Facility has bed bugs. It’s being alleged that a family member observed bed bugs in their relative’s room. The investigation revealed the following: S1-S6 all acknowledge being aware. S1 acknowledges being aware of the bed bugs and was told that it was previously suspected that the
Continued on 9099

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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-20210602160124

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
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA OF CHEVIOT HILLS	FACILITY NUMBER: 197609050
	VISIT DATE: 10/19/2021

NARRATIVE

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former resident might have brought them in via a couch. S1 sates the former resident no longer resides at the facility and the room is currently vacant. S2 states being aware of complaints of bed bugs and spiders from a family member and states seeing them in R5’s room. S3 states, seeing some about a “month and a half ago in R5’s room. S4 states “putting one in a glove to confirm it was an actual bed bug.” S5 states seeing some in R5’s room a month or two ago but hasn’t seen any since being sprayed. S6 states the facility is being treated for bed bugs.

During interviews with the residents the following was revealed: R1 was relocated to a sister facility and has since passed away and was unable to be interviewed. R2-4 state not seeing or being aware of any bugs in the facility, R5,6 were unable to answer interview questions due to cognitive ability. R7 states only seeing spiders. Reporting Party (RP) states seeing them on R1, on their clothing and belongings.

During a review of records, LPA discovered that the facility is contracted with Western Exterminator and has been treating the facility for bed bugs.

Based on the investigators interviews conducted with Administrator, caregivers, reporting party and 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 LIC9099-D.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210602160124

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
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA OF CHEVIOT HILLS	FACILITY NUMBER: 197609050
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/19/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (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. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Facility has entered into a contracted service to have the facility checked and treated every month with Western Exteminator. POC cleared during visit.
	8 9 10 11 12 13 14	Interviews and record review. Facility staff admits to seeing bed bugs and the facility admits to treament for bed bugs. This poses a health and safety 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: Angela J Kendrick	TELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy Agard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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