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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320456
Report Date: 07/31/2024
Date Signed: 07/31/2024 09:27:50 AM


Document Has Been Signed on 07/31/2024 09:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:TERRAZA COURT SENIOR LIVINGFACILITY NUMBER:
198320456
ADMINISTRATOR:HEZAR, JASMINEFACILITY TYPE:
740
ADDRESS:10955 WASHINGTON BLVDTELEPHONE:
(310) 838-7800
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:170CENSUS: DATE:
07/31/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brittany Kavanaugh,Baruch Berkowitz TIME COMPLETED:
09:25 AM
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Component II completion: Successful

Facility Type: RCFE
Application Type: CHOW
Capacity: 170
Census (if any clients in care): 70
COMP II Participants: Baruch Berkowitz (applicant/licensee), Brittany Kavanaugh (administrator)
Interview Method: Microsoft Teams

On 07/31/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISOR'S NAME: Mirella QuarantaTELEPHONE: (916) 657-2025
LICENSING EVALUATOR NAME: Susan NguyenTELEPHONE: (916) 657-2600
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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