198320456-7-19-2026-11-AS-JHAD-DWNQA7-20260805115927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 07/19/2026
Date Signed: 07/19/2026 12:32:26 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
03/06/2026 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260306170519

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: 105	DATE:	07/19/2026
		UNANNOUNCED	TIME BEGAN:	10:53 AM
MET WITH:	Queen Esther Blake		TIME COMPLETED:	11:59 AM

ALLEGATION(S):

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Staff did not prevent a resident from causing another resident to sustain a fracture while in care.

INVESTIGATION FINDINGS:

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On July 19, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted a subsequent an unannounced complaint visit. Queen Esther Blake, Activities Assistant, greeted the LPA. Ms. Blake contacted Linda Poythress, Executive Director by telephone and (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above.

The investigation included interviews, record reviews, and a tour of the facility. Investigation conducted by Investigator Dennis Douglas of the CDSS Investigation Branch. Interviews with Staff member S#1 - S#6 (S1-S6). The Department reviewed several documents, including the Facility Resident Roster (dated 03/05/26), Personnel Report LIC 500 (dated 02/28/26), (R1’s and R2’s) Physicians Report LIC 602 A (dated 010/02/24 and 01/02/25), Appraisal/Needs & Service Plan LIC 625 (dated 06/03/24, 07/22/24, 09/20/24 and 01/02/25), Hospice Care Notes (dated 01/01/26 – 03/06/26), Medication Administration Record (dated 02/01/26 – 02/28/26), County of Los Angeles Death Certificate (dated 05/28/26) and Culver City Police Station Report (#26001152). (Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026

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-20260306170519

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: 07/19/2026

NARRATIVE

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The Department reviewed hospice care notes dated from January 1, 2026, to March 6, 2026. During this time, Resident #1 (R1) was receiving hospice care. Hospice nurses were contacted and arrived at the facility the same day, accompanied by the responsible party. (R1) was not taken to the hospital; instead, hospice nurses treated (R1) at the facility in the following days. (R1) passed away at the facility five days later, on March 6, 2026, while under the care of the hospice staff. Reports also indicated that (R1) was regularly administered pain medication to alleviate (R1’s) discomfort until (R1’s) passing on March 6.

A further review of Resident #2 (R2's) "Resident Assessment/Service Plan (dated January 2, 2025) indicated that (R2) "may exhibit physically or verbally aggressive behavior" and might present "agitated or anxious behavior." This assessment also highlighted a "change of condition" relative to (R2’s) prior plan, (dated September 20, 2024). It was further revealed that (R2) had been prescribed antipsychotic and antidepressant medication. Nevertheless, (R2’s) Medication Administration Record (dated February 1, 2026 to February 28, 2026) showed that (R2) did not miss any doses in the weeks leading to the incident.

Further review of (R1’s) copy of the County of Los Angeles Death Certificate (dated May 28, 2026) listed "Blunt Trauma" as the cause of death. However, hospice care notes indicated that before the incident on March 1, 2026, (R1) had been diagnosed with "end-stage" Alzheimer's Disease and "advanced" Major Neurocognitive Disorder. It was noted that (R1) was very frail, weak, and debilitated, with poor prognosis. The objective of (R1’s) hospice care treatment was to ensure (R1) had comfort during that time.

The Department reviewed the Culver City Police Station Report (#26001152) and verified that the statements from all parties involved were accurate and consistent with the incident reporting. No charges were filed for elder abuse.

Based on the gathered information, it appeared that the facility was unaware of any previous instances involving Resident #1 and Resident #2 involving physical altercations or assaults and that staff acted promptly when the incident occurred. There is insufficient evidence to corroborate the allegation.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

No deficiencies cited.

An exit interview was conducted with QUEEN ESTHER BLAKE, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260306170519

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: 07/19/2026

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

ALLEGATION: Staff did not prevent a resident from causing another resident to sustain a fracture while in care.

It is alleged that the facility staff did not prevent a resident from causing another resident to suffer a fracture while under their care. Reports indicate that on March 1, 2026, Resident #1 (R1) was physically assaulted by Resident #2 (R2). Specifically, (R2) threw (R1) against the wall, causing (R1) to fall and break a hip. Additional reports state that (R1) passed away five days after the incident, on March 6, 2026. The incident was reported to the Culver City Police Department, though no further details have been provided.

On April 30, 2026, May 13, 2026, and May 29, 2026, between 02:00 PM and 03:20 PM, the Department interviewed staff members identified as Staff #1 through Staff #6 (S1-S6). Four (4) out of six (6) staff members could not corroborate this claim. (S2) was not working on the day of the incident, and (S6) became aware of it only after the incident occurred. According to (S1, S4, and S5), both residents were in the dining area of the memory care unit on March 1, 2026, when the incident took place. (S1, S4, and S5) explained that (R1) was trying to read a book that belonged to (R2), which (R2) had left on a table. (R2) became agitated when (R1) attempted to take (R2's) book, leading (R2) to push (R1) away. As a result of this push, (R1) fell to the floor, as confirmed by both (S4 and S5), who witnessed the incident. (S4) claimed to have been able to shield (R1) from striking (R1's) head against the wall; however, (R1) still fell and impacted (R1's) buttocks.

Meanwhile, (S3) learned about the incident from (S4 and S5) and acknowledged that after being notified, the responsible party for (R1) was contacted. The staff were instructed not to call 9-1-1 and were advised to leave (R1) on the floor, with the understanding that the responsible party would place (R1) back in bed. The staff followed the directives given by the responsible party. (S3) reported that hospice was contacted and arrived at approximately 3:45 PM on March 1, 2026. (S3) also noted that the facility did not have any surveillance cameras that could have captured the incident.

(S2-S6) acknowledged that (R1) exhibited wandering behaviors and would often roam throughout the memory unit, occasionally entering other residents' rooms, with staff members shadowing (R1) during these times. They also confirmed that (R2) had no prior incidents of aggression towards other residents and had not been involved in any physical altercations.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026

LIC9099 (FAS) - (06/04)

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