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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 08/08/2025
Date Signed: 08/08/2025 03:45:26 PM

Substantiated


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
06/25/2025 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20250625130052
FACILITY NAME:TERRAZA COURT SENIOR LIVINGFACILITY NUMBER:
198320456
ADMINISTRATOR:KAVANAUGH, BRITTANYFACILITY TYPE:
740
ADDRESS:10955 WASHINGTON BLVDTELEPHONE:
(310) 838-7800
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:170CENSUS: 109DATE:
08/08/2025
UNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Michelle Brown, Wellness DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not provide resident medication as prescribed.
INVESTIGATION FINDINGS:
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On 06/27/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegation(s). LPA met with Wellness Director Michelle Brown and the purpose of the visit was explained. LPA spoke with Executive Director over the phone. LPA conducted a subsequent visit on 07/10/25, 07/11/25 and 08/08/25 and met with the Wellness Director.

Investigation consisted of the following : On 06/27/25, LPA obtained Resident Rosters, Staff Roster, Elevator Invoices, Assisted Living and Memory Care Activity Schedule (January 2025 – June 2025), and Fire Drill Reports. LPA interviewed six (6) staff (S2 – S7) and toured the facility (stairwells 1 and 2), elevator, common areas, and outdoor patios. LPA received resident records via email on 07/07/25 – 07/09/25. On 07/10/25, LPA interviewed Staff #8 (S8), seven residents (R1 – R7), and Witness #1 (W1). On 07/11/25, LPA interviewed two staff (S9 – S10), five residents (R5, R8 – R11), and Witness #2. On 07/14/25, Executive Director emailed Medication Administration Records for five residents. Continue to LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
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-20250625130052
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: 08/08/2025
NARRATIVE
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On 08/01/25, Executive Director emailed August 2025 Activity Calendar and medication discontinuation and refill rosters for five residents. On 08/08/25, LPA conducted four (4) staff (S9 – S12) interviews and obtained identification and emergency information and needs and services plans for five memory care residents. LPA toured the common areas of the facility.
Investigation revealed the following
Allegation: Staff did not provide resident medication as prescribed
Record review of the facility’s Plan of Operation indicated that "medication refills will be obtained in a timely manner to ensure residents have all physician ordered medication available. 1) The designated staff member contacts the dispensing pharmacy to obtain a refill at least seven (7) days prior to running out of a medication, unless medication is on a cycle refill with the pharmacy…. 2) If necessary, the prescribing physician is contacted for a new order. 3) Medications are never allowed to run out unless directed to by the physician (obtain this direction in writing). Record review of R1’s February 2025 Medication Administration Record (MAR) revealed that medication A was out of stock as of 02/20/25, medication B as of 02/22/25, medication C and D as of 2/23/25, and medication E and F as of 02/26/25. Record review of R1’s refill order did not provide a refill date request for medication A and B. Medication C, D, and E refills were requested on 02/21/25. Medication F refills was requested on 02/26/25. Record review of R4’s July 2025 MAR revealed medication A was missed on 7/2, 7/6, 7/8, 7/10, 7/12, and was requested to be refilled on 07/17/25. Medication B was missed on 7/4, 7/6, 7/10 and requested to be refilled on 7/17/25. Record review of R5’s July 2025 MAR revealed medication A was unavailable from 07/09/25 – 07/13/25 and the request for refill was submitted 07/16/25. Medication B was missed 07/03/25, 07/09-07/10, 07/12-07/13 AM and 07/07, 07/09 - 07/12 PM and was requested to be refilled on 07/16/25. Medication C was missed on 7/2 - 7/3, 7/6 - 7/7, 7/9 - 7/12. Record review of R12’s March 2025 MAR revealed R12’s medication A – G was out of stock as of 03/19/2025. Record review of R14’s May 2025 MAR revealed medication A was missed on 5/1 - 5/4, 5/6 - 5/11, 5/13, 5/15 - 5/19, 5/21 - 5/24, 5/29 - 5/31 and medication B was missed on 5/1, 5/5-5/7, 5/10, 5/13, 5/17-5/19, and 5/24.

Regarding the allegation, “Staff did not provide resident medication as prescribed” based on record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6 and Chapter 8 on the attached LIC 9099D.
An exit interview was conducted, plans of correction developed, and a copy of this report with appeals was provided to the Wellness Director Michelle Brown.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250625130052
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2025
Section Cited
CCR
87208(a)
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87208 Plan of Operation (a) The licensee shall ... operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49...

This requirement was not met as evidence by:
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The Licensee will submit a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.
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Based on record review, the Licensee did not follow its plan of operation: medication policy (medication refills) for Residents #1, 4, 5, 12, and 14 which poses a potential health risk for resident in care. Plan indicates medications are never allowed to run out and refills will be ordered 7 days in advanced.
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3