198602264-10-30-2020-11-AS-EMAZ-BVPW58-20201125155842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 10/30/2020
Date Signed: 10/30/2020 04:14:12 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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2020 and conducted by Evaluator Stephanie Cifuentes

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200501163028

FACILITY NAME:	TERRAZA COURT		FACILITY NUMBER:	198602264
ADMINISTRATOR:	ZAMUDIO, JESSE		FACILITY TYPE:	740
ADDRESS:	10955 WASHINGTON BLVD		TELEPHONE:	(310) 838-7800
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	115	CENSUS: 61	DATE:	10/30/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Greg Becker		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not meeting resident's needs due to lack of staffing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Greg Becker, the facilities interim-Executive director.

The investigation consisted of the following:

On 5/6/2020 LPA Cifuentes conducted a telephone video call with the administrator. During the call, LPA Cifuentes spoke with administrator, was shown dining room, kitchen, activity room, courtyard, memory care on second floor and the assisted living sections on the second and third floor. LPA requested time sheet reports for April 19-25 2020, January 5-11, 2020, as well as staff schedule for month of April be sent via fax to CCL. As these could not be obtained, LPA was given staff scheduled from December 2019 to April 2020. On 5/20/2020 LPA conducted interviews with staff 1-5 as well as resident 1. On 5/21/2020 LPA conducted interviews with residents 2-resident 8 as well as staff person 6.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

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-20200501163028

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
MONTERY PARK, CA 91754

FACILITY NAME: TERRAZA COURT	FACILITY NUMBER: 198602264
	VISIT DATE: 10/30/2020

NARRATIVE

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Regarding the allegation: Staff are not meeting residents needs due to lack of staffing.

The investigation revealed the following:

On 5/6/2020 LPA toured facility. LPA saw dining room, activity room, kitchen and a few resident bedrooms.

On 5/22/2020 and 5/26/2020 LPA reviewed facility records. Staffing schedule provided to LPA show that in general two caregivers are assigned to assisted living and two are assigned to memory care. On March 2, 2020, facility had one caregiver assigned to memory care and one caregiver assigned to assisted living during the AM shift. On April 21, 2020 there was only one caregiver assigned to assisted living and again the same on April 27, 2020. On April 26 there was one caregiver assigned to memory care.

On 5/21 and 5/22/2020 LPA interviewed residents 1-8. Of the resident’s interviewed 5 out 0 8 stated they believed their need were being met. 4 out of 8 residents stated they did not believe facility had enough staff.

On 5/20/2020 and 5/22/2020 LPA Cifuentes interviewed facility staff. 5 out of 6 staff stated that they did not believe facility was sufficiently staffed and that clients needs were not being met.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200501163028

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
MONTERY PARK, CA 91754

FACILITY NAME: TERRAZA COURT	FACILITY NUMBER: 198602264
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/13/2020 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required...	1 2 3 4 5 6 7	Executive director agreed to submit a plan on how to ensure that there is sufficient staff to meet residents needs.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews conducted and records reviewed the licensee failed to ensure that there is sufficient staff to meet the residents care needs. This poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC9099 (FAS) - (06/04)

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