198320456-5-9-2025-11-AS-JHAD-DJ7VUJ-20250702164445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 11/14/2024
Date Signed: 05/09/2025 10:13:33 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
11/07/2024 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20241107165127

FACILITY NAME:	TERRAZA COURT SENIOR LIVING		FACILITY NUMBER:	198320456
ADMINISTRATOR:	KAVANAUGH, BRITTANY		FACILITY TYPE:	740
ADDRESS:	10955 WASHINGTON BLVD		TELEPHONE:	(310) 838-7800
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	170	CENSUS: 74	DATE:	11/14/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Michelle Brown		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not prevent a resident from sustaining a fracture while in care.
Staff did not prevent resident from eloping from the facility.

INVESTIGATION FINDINGS:

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*** This amended complaint report dated 04/17/2025, supersedes the original report dated 11/14/2024***On 04/17/2025, Licensing Program Analyst (LPA) Pamela Bunker conducted a subsequent visit to gather information regarding the above allegations. LPA met with Michelle Brown, Director of Wellness, and explained the purpose of the visit. LPA was granted entry to the facility.

The investigation consisted of the following: On 04/17/2025, documents were reviewed/obtained: Personnel report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician's Report, Medical Assessment, Medication Administration Records (MARs), Appraisal & Needs Service Plan, Functional Capability Assessment, Preplacement Appraisal Information, Consent Forms, and UCLA Medical Center Record. Interviews were conducted with staff members 1-4 (S1-S4) and residents 2-8 (R2-R8). Resident 1 (R1) was unavailable for an interview and no longer resides at the facility. R1 passed away on 12/21/2024, after relocating to another facility.
See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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-20241107165127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA COURT SENIOR LIVING	FACILITY NUMBER: 198320456
	VISIT DATE: 11/14/2024

NARRATIVE

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Continued LIC9099-C page 2

LPA and staff toured the facility's buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No evidence of neglect or abuse was observed during these visits.

Investigation revealed the following:

Allegation: Staff did not prevent a resident from sustaining a fracture while in care.
It was alleged that on 10/24/24, the resident got out of the facility and fell while walking backward. The resident was taken to the emergency room, where the resident was found to have a hip fracture. 4 out of 4 staff interviewed stated that R1, who has Dementia and Parkinson's and experiences tremors, suddenly began walking backward, repeatedly saying that someone was kidnapping their daughter. As R1 attempted to turn around, the resident accidentally tripped over their own foot and fell on their back. S2-S4, (3 out of 4) stated that the incident happened so quickly that they could not have prevented R1 from falling.

Interviews with staff members 1-4 (S1-S4) reported that on October 24, 2024, at approximately 9:50 P.M., R1 experienced an accidental fall and sustained a fracture while in care. S1-S4 reported that Residents 1 and 2 (R1 & R2) were wandering in the Memory Care Unit when R2 triggered the egress door alarm, and it went off. Staff immediately responded, running to the door to assist and redirect the two residents. The Med Tech immediately called Emergency 911 services without delay, contacted the resident’s responsible party, Power of Attorney(POA), and the physician was notified. 3 out of 4 assured that no one pushed R1, emphasizing that staff were present to assist and care for both residents the entire time, and R1 was transported to UCLA Medical Center per the daughter's request. According to S1-S4, the fall was unavoidable, and the staff was present the entire time. 4 out of 4 staff members stated that R1 was not considered a fall risk. R1 was ambulatory and had no history of falls. The facility did not have any surveillance camera footage of the incident.

Interviews with Residents 2-8 (R2-R8). 7 out of 8 indicated that none of them witnessed the fall or any other instance of a resident falling or attempting to leave the facility. R2-R8 expressed that they feel safe, are happy with the care and supervision provided, and believe that the staff are doing a wonderful and great job.

See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20241107165127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA COURT SENIOR LIVING	FACILITY NUMBER: 198320456
	VISIT DATE: 11/14/2024

NARRATIVE

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Continued LIC9099-C page 3

Residents R2-R8 stated that staff members are consistently available to assist and expressed satisfaction with their living conditions and the care provided. Both S1-S4 and R2-R8 state that the accommodations provided are comfortable and that the staff is dedicated to ensuring the safety and well-being of all residents.
Staff 1-4 (4 out of 4) stated that the Special Incident Report was submitted, and the resident's family, Power of Attorney (POA), responsible party, physician, Community Care Licensing, and all appropriate agencies were notified in a timely manner.
S1-S4 and R2-R8 denied the allegation.

Investigation revealed the following:

Allegation: Staff did not prevent a resident from eloping from the facility.
It was alleged staff did not prevent a resident from eloping from the facility and the resident was able to get out of the facility.

Interviews with staff members 1-4 (S1-S4) 4 out of 4 staff stated that R1 never eloped from the facility but was only five steps in front of the Memory Care Unit door. 4 out of 4 staff stated that at no point did the resident leave the building, and staff remained present to provide assistance throughout the incident. S1-S4 emphasized that the facility operates on a 24/7 basis, ensuring that residents are never left unattended.

Interviews with Residents 2-8 (R2-R8). 7 out of 8 indicated that none of them witnessed any resident eloping from the facility. They expressed feeling safe, and satisfied with the care and supervision provided, and believe that the staff is doing great and wonderful job and maintaining a secure, comfortable environment.
S1-S4 and R2-R8 denied the allegation.

The medical records from UCLA stated staff is not at fault for the resident's fall. The facility reported the special incident in a timely manner to Community Care Licensing and all the appropriate agencies stating the resident had accidentally fallen. The facility had no surveillance cameras to capture the fall.
See continued LIC9099-C page 4

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20241107165127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA COURT SENIOR LIVING	FACILITY NUMBER: 198320456
	VISIT DATE: 11/14/2024

NARRATIVE

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Continued LIC9099-C page 4

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Wellness Director Michelle Brown.

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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