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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602264
Report Date: 06/27/2022
Date Signed: 06/27/2022 03:41:10 PM


Document Has Been Signed on 06/27/2022 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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: 59DATE:
06/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Greg BeckerTIME COMPLETED:
02:30 PM
NARRATIVE
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On 6/27/2022, LPA Lourdes Montoya conducted a case management visit - deficiency at the above facility. LPA was assisted by Administrator Greg Becker. While LPA Montoya was conducting an unrelated complaint visit, LPA observed the following deficiency.

Based on record review and interview, Resident #1's Physician's Report on file dated April 27, 2017 shows Resident #1 has a dementia. LPA did not observe a current Physician's Report for Resident #1. LPA asked Administrator Becker for the most current report, Becker confirmed he found only one Physician's Report on file. Licensee failed to ensure Resident #1 who has a dementia had medical assessment done annually.

California Code of Regulations, Title 22, Division 6, and Chapter 1 is being cited on the attached LIC 9099D.

Exit interview conducted and a copy of the appeal rights was issued and discussed with Administrator Greg Becker.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2022 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/04/2022
Section Cited

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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by:
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Based on record review and interview, Resident #1's Physician's Report on file dated April 27, 2017 shows Resident #1 has a dementia. LPA did not observe a current Physician's Report for Resident #1. LPA asked Administrator Becker for the most current report, Becker confirmed he found only one Physician's Report on file. Licensee failed to ensure Resident #1 who has a dementia had medical assessment done annually. This poses a potential risk to Resident's health, safety and/or personal rights 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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2022
LIC809 (FAS) - (06/04)
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