198320456-2-19-2025-11-AS-SCIS-DK523L-20250731170228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 01/15/2025
Date Signed: 02/19/2025 01:58:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/26/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20241126115531

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: 79	DATE:	01/15/2025
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Brittney Kavanaugh, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not provide adequate care and supervision to a resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 1/15/25.

On 1/15/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted a subsequent unannounced visit to this facility. LPA was met by Executive Director, Brittany Kavanaugh and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 12/2/24, LPA Shirley spoke to facility Executive Director, Brittany Kavanaugh and reviewed facility records. LPA requested copies of staff and resident rosters, Shower schedule, and special incident reports involving R-1. LPA also interviewed staff 1 thru staff 10 and residents 2 thru resident 7. LPA received copies of residents, Admissions Agreement, Emergency Contacts, Physician’s report, preplacement appraisal, Appraisal/Needs and Services Plan, Staff Schedule, Resident Assessment, and Assessment for Medication Self-Management.
Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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 3

Control Number 11-AS-20241126115531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TERRAZA COURT SENIOR LIVING	FACILITY NUMBER: 198320456
	VISIT DATE: 01/15/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff did not provide adequate care and supervision to a resident.

On the evening of 11/3/24, R1 sat on the edge of the shower chair and accidentally fell in the shower and was found at 6:15am the next morning attempting to get up from the bathroom shower floor by S9. S9 went to R1’s room to check on the resident and remind her to come to breakfast. S9 immediately assisted the resident as R1 stated she was cold and stated that she could not reach the pull cord. The responsible party stated that R1 had been shouting for help since 6pm the evening before but no one heard her. Per S9, R1 stated that she did not want to go to see doctor but S9 advised her that she should be checked out by a doctor. S9 promptly called for assistance, and Med Tech S-3 responded immediately. The Med Tech called 911 without delay, and the resident was transported to Southern California Hospital at Culver City. The resident’s responsible party was notified.

Per S2, R1 does not receive one-on-one care. R1 is independent and is residing in the Assisted Living unit of the facility. S1 stated that resident is ambulatory, uses a walker, not a fall risk and does not show signs of being unsteady. LPA Felisa Shirley toured the facility with S2 and went to R1’s room to verify if the pull cord worked. LPA Shirley pulled the pull cord in the bathroom located between the toilet and the shower. Once the cord was pulled, the unit displayed the word, HELP! LPA Shirley then heard on S2’s walkie and the caregiver's walkie in the hallway, that the staff at the front desk received an alert from R1’s room. Upon review of shower list, R1 was not on the shower list as per R1’s physician’s report and Needs and Service plans she is able to dress and groom herself. There is not a Medication Administration Record, (MAR) for R1. Per resident’s physicians report, Needs and Service Plans, Resident Assessment, and Assessment

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20241126115531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TERRAZA COURT SENIOR LIVING	FACILITY NUMBER: 198320456
	VISIT DATE: 01/15/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

for Medication Self-Management, R1 was independent and able to administer her own prescription medications. LPA Felisa Shirley spoke with the responsible party and they stated that R1 did not like to be disturbed during the night when she slept.

LPA Shirley spoke with and interviewed staff 1 thru staff 10 (S-1 thru S-10). LPA ask, does staff provide adequate care and supervision to residents in care? Of those interviewed, 9 out of 10 answered yes. One staff answered, sometimes. LPA Shirley interviewed residents 2 thru resident 7 (R-2 thru R-7). R1- was not available for interview. LPA ask, does staff provide adequate care and supervision to residents. Of those interviewed, 6 out of 6 answered yes.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation 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 allegation is unsubstantiated.

A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Executive Director Brittany Kavanaugh. There were no deficiencies cited. An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3