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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 09/17/2021
Date Signed: 09/17/2021 12:26:33 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/07/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210607153958
FACILITY NAME:TERRAZA COURTFACILITY NUMBER:
198602264
ADMINISTRATOR:GREG BECKERFACILITY TYPE:
740
ADDRESS:10955 WASHINGTON BLVDTELEPHONE:
(310) 838-7800
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:115CENSUS: 67DATE:
09/17/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Greg Becker, Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Resident hit by another resident while in care resulting in injury.
Staff mismanaged residents' medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Greg Becker, the facility’s Executive Director.

The investigation consisted of following: Interviews and Record reviews. On 08/30/21, LPA Soto interviewed Executive Director, S#2 - S#5, and R#1 - R#6. LPA Soto and Executive Director toured, Memory Care Unit rooms and 1 assisted living room #101, #122A, #125, #136, #138, hygiene storage supplies, lobby, facility phone and cell phone storage, and 2 lobby common restrooms. LPA Soto received the following documents on 08/30/21; Resident Roster, Staff Schedule, Face sheet, Physician's Report, Admission Agreement, Resident assessment, Needs and Services Plan, and photos (R#1 room, bathroom, cell phone and refrigerator) , (1) SIR, and MARS for (May and June 2021.)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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 5
Control Number 11-AS-20210607153958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TERRAZA COURT
FACILITY NUMBER: 198602264
VISIT DATE: 09/17/2021
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following. For Allegation 1 – Resident hit by another resident while in care resulting in injury. Interviews with the Executive Director stated that they did have an incident where 2 residents got into an altercation. The facility sent an SIR to CCLD and provided a copy to LPA Soto. Both R#1 and R#2, where sent to the 2 different hospital R#1 went UCLA Marina del Rey and R#2 went to USC hospital. R#1 sustained blunt head trauma and R#2 sustained a pelvic fracture. LPA Soto reviewed the hospital discharge documents from both hospitals. Interviews with S#2 – S#5, stated they were not aware of any residents involved in an altercation. Interviews with R#2 – R#6, could not answer any of the questions LPA Soto asked the residents. They all just kept quiet, but sometimes mumbled random words. The interviews and records reviewed did concur with above allegation.

For Allegation 2 – Staff mismanaged residents' medications. Interviews with the Executive Director and S#2 – S#5, stated that the medication technician always gives the residents their medication. LPA reviewed the MARS for R#1 & R#2, they had missing doses and the facility could not explain to LPA Soto why the doses were missed. Interviews with R#2 – R#6, could not answer any of the questions LPA Soto asked the residents. They all just kept quiet, but sometimes mumbled random words. The records reviewed did concur with above allegation.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued a citations.

An exit interview was conducted with Greg Becker, Executive Director and a hard copy was provided along with Appeal Rights.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/07/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210607153958

FACILITY NAME:TERRAZA COURTFACILITY NUMBER:
198602264
ADMINISTRATOR:GREG BECKERFACILITY TYPE:
740
ADDRESS:10955 WASHINGTON BLVDTELEPHONE:
(310) 838-7800
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:115CENSUS: 67DATE:
09/17/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Greg Becker, Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Resident's diapering needs are not being met.
Resident's showering needs are not being met.
Facility does not have an adequate supply of diapering supplies.
Facility restrooms are dirty.
INVESTIGATION FINDINGS:
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3
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5
6
7
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9
10
11
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13
Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Greg Becker, the facility’s Executive Director.

The investigation consisted of following: Interviews and Record reviews. On 08/30/21, LPA Soto interviewed Executive Director, S#2 - S#5, and R#1 - R#6. LPA Soto and Executive Director toured, Memory Care Unit rooms and 1 assisted living room #101, #122A, #125, #136, #138, hygiene storage supplies, lobby, facility phone and cell phone storage, and 2 lobby common restrooms. LPA Soto received the following documents on 08/30/21; Resident Roster, Staff Schedule, Face sheet, Physician's Report, Admission Agreement, Resident assessment, Needs and Services Plan, and photos (R#1 room, bathroom, cell phone and refrigerator) , (1) SIR, and MARS for (May and June 2021.)

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20210607153958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TERRAZA COURT
FACILITY NUMBER: 198602264
VISIT DATE: 09/17/2021
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following. For Allegation 1 – Resident's diapering needs are not being met. Interviews with Executive Director, S#2 – S#5, stated that the residents are not left in soiled diapers. LPA Soto observed the hygiene supplies, they had enough diapers for the whole facility. Interviews with R#2 – R#6, could not answer any of the questions LPA Soto asked the residents. They all just kept quiet but mumbled random words. The interviews and records reviewed did not concur with above allegation.

For Allegation 2 – Resident's showering needs are not being met. Interviews with Executive Director, S#2 – S#5, stated that they bathe the residents when the schedule says they are required baths. LPA Soto reviewed shower schedule for Memory Unit, it revealed that all the residents that are on the list get their showers as scheduled. Interviews with R#2 – R#6, could not answer any of the questions LPA Soto asked the residents. They all just kept quiet but mumbled random words. The interviews and records reviewed did not concur with above allegation.

For Allegation 3 – Facility does not have an adequate supply of diapering supplies. Interviews with Executive Director, S#2 – S#5, stated that they do have enough diapers, the diapers are always kept in the supply room and are available for the staff to get when they need them. LPA Soto observed the hygiene supplies, they had enough diapers for the whole facility. Interviews with R#2 – R#6, could not answer any of the questions LPA Soto asked the residents. They all just kept quiet but mumbled random words. The interviews and records reviewed did not concur with above allegation.

For Allegation 4 – Facility restrooms are dirty. Interviews with Executive Director stated that they are always clean house keeping are good at cleaning the all restrooms (common and resident.) Interviews with S#2 – S#5, stated that before the bathrooms were dirty, but now they are clean. The house keepers are doing a great job of cleaning all the facilities restrooms. LPA Soto observed 2 common area restrooms and 5 residents’ restrooms, they were all clean and operational. Interviews with R#2 – R#6, could not answer any of the questions LPA Soto asked the residents. They all just kept quiet but mumbled random words. The interviews and records reviewed did not concur with above allegation
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Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated

An interview was conducted with Greg Becker, Executive director, and a hard copy was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210607153958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA COURT
FACILITY NUMBER: 198602264
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2021
Section Cited
CCR
87307(a)(2)
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87307(d)(2) - The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This was not met as evidence by Based on observation and interviews, 2 resdient got into an altercation, which poses a potential health, safety to persons in care.
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Executive Director to outline procedure and how to avoid these further incidents from occurring in the future by POC due date 10/01/21. Will send LPA Soto an email with the above information
Type B
09/17/2021
Section Cited
CCR
87464(f)(4)
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87464(f) (4) - Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.
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Executive Director will porvide a training for all med tech to attend regarding - Policies and procedures for medications. By POC due date 10/01/21. Will send LPA Soto the sign sheet and description of the type of training given.
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This was not met as evidence by Based on observation and interviews, med tech failed to give medication to resident which poses a potential health, safety to persons in care.
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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.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5