198602264-4-1-2022-11-AS-JHAD-CDN277-20220419170817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 04/01/2022
Date Signed: 04/01/2022 05:12:46 PM

Unsubstantiated

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
03/24/2022 and conducted by Evaluator Martessa Brown

COMPLAINT CONTROL NUMBER: 11-AS-20220324113509

FACILITY NAME:	TERRAZA COURT		FACILITY NUMBER:	198602264
ADMINISTRATOR:	GREG BECKER		FACILITY TYPE:	740
ADDRESS:	10955 WASHINGTON BLVD		TELEPHONE:	(310) 838-7800
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	115	CENSUS: 60	DATE:	04/01/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Galina Tormasian Business Manager		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not release resident records to responsible party
Facility staff failed to notify residents reporting party of an incident.

INVESTIGATION FINDINGS:

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On 4/1/22, Licensing Program Analysts (LPAs) Martessa Brown, Jeremiah Randle and Licensing Program Manager (LPM) Janae Hammond conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Galina Tormasian, Office manager and Greg Becker, Administrator and the purpose of the visit was explained.

The investigation consisted of the following:

On 3/24/22 LPA received a complaint investigation, Resident R1 had passed away on 1/15/21 and the reporting party stated the administrator did not notify them of the resident’s condition and would not release the resident’s records. On 4/1/22, LPAs met with the administrator and requested the following document LIC 500 & resident roster, Incident reports, Resident (R1) physician and Death Report, Identification/Emergency contact and Admissions Agreement.
The investigation revealed the following:

LIC9099-C is on the next page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

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-20220324113509

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: 04/01/2022

NARRATIVE

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Facility did not release resident records to responsible party

On 4/1/22 LPAs reviewed R1’s physician and death reports, Identification/Emergency Contact and there was no emergency contact or Conservator/Power of Attorney listed in the resident file. On 4/1/22 LPAs conducted an interview with Administrator Greg Becker regarding the above allegation. He stated resident has been in the facility since 2016. He stated the resident had became ill and had to move to skill nursing. He stated the resident had passed away at the skill nursing. He stated had checked R1’s file and there was no Conservatorship or POA on file. On 4/1/22 LPA spoke the Social Worker (SW) from the skilled nursing facility. SW stated resident was admitted on 1/8/21 and was there for 1 year. SW stated R1 and later had passed away. SW stated resident did not have an emergency contact on file and they conducted their own investigation and did not find any POA or emergency contact.

Facility staff failed to notify residents reporting party of an incident.

On 4/1/22 LPAs conducted an interview with Greg Becker, the Administrator. He stated R1 had moved to a skilled nursing facility on 1/8/21 and was notified that R1 had passed. He stated R1 did not have any Conservatorship or POA on record to notify of R1’s passing. On 4/1/22 LPAs conducted an interview with SW and stated based on records review for R1 and there was no Emergency Contact or Conservatorship on file. SW also stated did not receive any notification or was contact that R1 had any type of POA.

Based on interviews conducted and records review, although the allegation 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 allegation is unsubstantiated.

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

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022

LIC9099 (FAS) - (06/04)

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