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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 10/28/2022
Date Signed: 10/28/2022 01:56:34 PM

Substantiated


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
09/13/2022 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220913151630
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: 57DATE:
10/28/2022
UNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Stephanie Funderburg, Acting AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident had a fall resulting in injury
INVESTIGATION FINDINGS:
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On 10/28/2022, Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation to address the allegations listed above. LPA Agard met with Stephanie Funderburg, Acting Administratorand explained the purpose of this visit is to deliver findings.

The investigation consisted of the following: LPA Agard conducted a tour of the facility grounds. The facility is a three-story commercial building. The first floor indicated as “L” consist of the lobby/receptionist area, business offices, living room, library/activity room, dining area, kitchen, staff break room, laundry and medication room. The first and second floor consist of resident's bedrooms and bathrooms, storage, and patio. The Memory Care Unit (MCU) is located on the 1st floor and consist of bedrooms and bathrooms, resident's laundry room, dining/activity room, small kitchen, TV room, offices, and patio. LPA interviewed staff, residents, and reviewed records. LPA Agard requested the following documents, which were received at the time of visit: 1) a copy of the staff roster, 2) a copy of the resident roster, 3) needs and services plans for R1, 4) physician report for R1, 5) Incident reports in the past 30 days, 6) any correspondents from Department of Public Health. 7) any relevant information to this complaint.

Cont. on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
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 7
Control Number 11-AS-20220913151630
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: 10/28/2022
NARRATIVE
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The investigation revealed the following: Regarding the allegation: Resident had a fall resulting in injury. It’s being alleged that staff had no idea how the resident fell or what they hit their head on. On 09/19/2022 LPA interviewed 5 out of 35 staff. 2 out of 5 confirmed the allegation. S1 states, “I can’t confirm the residents fall or what they hit their head on.” S2 states, “R1 did have an unwitnessed fall and had to have stitches.” S3 states, “R1 recently went to the hospital for a fall. I don’t know how they fell because it was unwitnessed.” S5 states, “I heard about it, but I don’t personally know.”

During interviews with residents, LPA interviewed 5 out of 57 residents, 0 out of 4 confirmed the allegation. R1 was unable to answer the questions. R2 states “I’m not aware of anyone having a fall and I have not had any falls myself.” R3 states, “I have not had any falls or witnessed any falls that resulted in injuries. I don’t know anyone who has.” R4 states, “I have not heard or seen any residents having a fall.” R5 states, “I haven’t witnessed any falls. I used to fall a lot that’s the reason I’m here.”



During a record review, LPA reviewed the following records: A staff and resident roster that coincides with the staff and residents interviewed. LPA Agard reviewed an incident report dated 09/06/2022 that was fax to licensing explaining R1 had an unobserved fall.

Based on LPA’s observation, interviews conducted, and record review, 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 Chapter 8 is being cited (please see LIC9099D.)

An exit interview was conducted. Plans of correction were developed. A copy of this report and appeal rights were given.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
09/13/2022 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220913151630

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: 57DATE:
10/28/2022
UNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Stephanie Funderburg, Acting AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Residents room had not been cleaned
Residents laundry was not done timely
Resident left in soiled diapers
Resident left in soiled bedding
Resident's blinds are in disrepair
INVESTIGATION FINDINGS:
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On 10/28/2022, Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation to address the allegations listed above. LPA Agard met with Stephanie Funderburg, Acting Administratorand explained the purpose of this visit is to deliver findings.

The investigation consisted of the following: LPA Agard conducted a tour of the facility grounds. The facility is a three-story commercial building. The first floor indicated as “L” consist of the lobby/receptionist area, business offices, living room, library/activity room, dining area, kitchen, staff break room, laundry and medication room. The first and second floor consist of resident's bedrooms and bathrooms, storage, and patio. The Memory Care Unit (MCU) is located on the 1st floor and consist of bedrooms and bathrooms, resident's laundry room, dining/activity room, small kitchen, TV room, offices, and patio. LPA interviewed staff, residents, and reviewed records. LPA Agard requested the following documents, which were received at the time of visit: 1) a copy of the staff roster, 2) a copy of the resident roster, 3) needs and services plans for R1, 4) physician report for R1, 5) Incident reports in the past 30 days, 6) any correspondents from Department of Public Health. 7) any relevant information to this complaint.

Cont. on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
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 7
Control Number 11-AS-20220913151630
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: 10/28/2022
NARRATIVE
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Regarding the allegation: Residents room had not been cleaned. “It’s being alleged a resident’s room was observed with clothes all over the floor. The floor of the room and bathroom had not been swept.” On 09/19/2022 LPA interviewed 5 out of 35 staff. 0 out of 5 confirmed the allegation. S1 states, “I can’t say that the room was dirty, was the closet in a disarray, yes but I can’t say that the staff did that or the resident.” S2 states, “I’m unfamiliar with that because we do have a full-time housekeeper there.” S3 states, “there was a time when the room was not completely clean but that’s because housekeeping hadn’t gotten to that room yet. In general, it’s not an issue. S5 states, “I can clean a room and it can be dirty in a few. That’s just how memory care works.”

During interviews with residents, 2 out of 4 confirmed the allegation. R1 was unable to answer the questions. R2 states, “I don’t have any problems with housekeeping cleaning the room. If you have a problem with that, if anything, you let them know right away and they will take care of it.” R3 states, “no, it’s not being cleaned regularly, and I have to ask for it to be cleaned. When I first moved here it was every other Tuesday but now, they don’t do it.”


R4 states, “yes, my room is clean, they are doing it pretty regularly.” R5 states, “most of the time it’s not cleaned. I have a problem with them coming to clean. I call them and it takes them awhile to come.”

Regarding the allegation: Residents laundry was not done timely. “It’s being alleged there was no clean bedding or clean clothes to change the resident.” 0 out of 5 confirmed the allegation. S1 states, “all the laundry was pulled and rehung that day, within hours actually.” S2 states, “we were following the Covid policy procedure from LA County Dept of Health for the laundry in memory care. LA county doesn’t want us mixing laundry, so we have a procedure. Laundry was available. We have procedures and wasn’t schedule to complete laundry until the afternoon based on the recommendation.” S3 states, “laundry was being done that day, they just hadn’t gotten to her room yet due to covid and being on isolation. Laundry has slowed down, and the staff are the ones doing it. It got done that day.”

During interviews with residents, 0 out of 4 confirmed the allegation. R1 was unable to answer the questions. R2 states, “my laundry is done on time and the lady is really nice. She folds them so nicely. She does a great job.” R3 states, “oh yes, my laundry is being done timely. I just love her. She does a good job.” R5 states, “I love the lady that does my laundry, she does it on Tuesday for me.”

cont on 9099C
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20220913151630
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: 10/28/2022
NARRATIVE
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Regarding the allegation: Resident left in soiled diapers. “It’s being alleged a residents’ diaper had not been changed.” 0 out of 5 confirmed the allegation. S1 states, “I wasn’t informed about the resident being wet.” S2 states, “it’s highly unlikely. Staff are doing extra rounds because everyone is isolated, so they have to physically go on and check on the residents.” S3 states, “I don’t know about that.” S4 states, “I don’t think so but I’m not sure.” S5 states, “I’ve never witnessed any one being in a soiled diaper.”

During interviews with residents, 0 out of 4 confirmed the allegation. R1 was unable to answer the questions. R2 states, “I don’t know about that.” R3 states, “I don’t know and have not heard anything about soiled diapers.” R4 states, “yes, my diaper is changed by staff. At least twice a day and if I ask them. Sometimes I worry about running out. R5 states, “not that I know of.”

Regarding the allegation: Resident left in soiled bedding. “It’s being alleged a resident had been laying and sitting in their urine/feces for an extended time.” 0 out of 5 confirmed the allegation. S1 states, “I couldn’t tell you if the bedding was soil or clean.” S2 states, “the only thing I could think of is if a residents diaper became wet, I could see the sheets becoming wet. When I went up there the staff had already been on it.” S3 states, “I don’t know if R1’s bed sheets were wet. It wasn’t mentioned.” S4 states, “I have not observed R1’s bedding being soiled or the room having a smell.” S5 states, I’ve been in R1’s room but their bed is always getting changed.

During interviews with residents, 0 out of 4 confirmed the allegation. R1 was unable to answer the questions. R2 states, “I don’t know about soiled bedding because I’m able to take care of myself and I have not heard anything about that.” R3 states, “I don’t know and have not heard anything about soiled bedding.” R4 states, “it’s my fault, I sometimes wet the bed because I can’t help it but the staff change it right away.” R5 states, “not that I know of. Everything is fine regarding my bedding.”

Regarding the allegation: Resident's blinds are in disrepair. “It’s being alleged a resident window blinds were all over the floor.” 0 out of 5 confirmed the allegation. S1 states, I checked the blinds one day and put them back up, only to go back a few hours later and saw that they had pulled them down on the floor. With R1 having one in their hand while lying on the bed. S3 states, we fixed them that day but literally the resident will pull them down. S5 states, “The blinds, that’s part of my job and it’s a constant battle. I will put them up and it gets torn down. They just pull them down.”

cont. on 9099C
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20220913151630
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: 10/28/2022
NARRATIVE
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During interviews with residents, 0 out of 4 confirmed the allegation. R1 was unable to answer the questions. R2 states, “my room is in good standings; window blinds are fine. I have no issues and don’t know of anyone that has had issues.” R3 states, “My window blinds are good; they are not broken.” R4 states, “my window blinds are not broken.” R5 states, “yea, my window blinds are in good shape.”

During a record review, LPA reviewed the following records: A staff and resident roster that coincides with the staff and residents interviewed. LPA Agard reviewed a laundry schedule which outlined assisted living and memory care’s laundry schedule. LPA Agard reviewed documentation from the health department which corroborates S1 statement regarding recommendation on laundry services which might result in delays due to covid outbreak. During a visit on 09/19/2022, 09/28/2022 and again on 10/28/2020, LPA observed R1’s room to be clean, with appropriate dry bed linen and window blinds in place.

Based on interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation(s) is unsubstantiated.

An exit interview was conducted, and a copy of the report was given.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20220913151630
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: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Facility will review and retrain staff on supervision protocols for memory care residents. Training and sign-in sheet will be sent to LPA on or before POC due date.
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This requirement was not met as evidence by: Based on a record review, facility self-reported a resident had an unwitnessed fall which resulted in injury. .
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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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7