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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602264
Report Date: 12/13/2022
Date Signed: 12/16/2022 08:43:41 AM


Document Has Been Signed on 12/16/2022 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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: 57DATE:
12/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:DAN GORMLEYTIME COMPLETED:
03:00 PM
NARRATIVE
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On 12/13/2022, LPA Lourdes Montoya conducted a case management- deficiency visit observed during a separate complaint visit. LPA met with Regional Operations Specialist (ROS) Dan Gormley.

Based on LPA's review of the Facility Personnel Summary Report Teresa WIliams/Medication Technician has no background clearance and not associated to the facility. Business Office Manager Galina Tovmasian and Regional Operations Specialist Dan Gormley are not associated to the facility.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted and Appeal Rights was discussed with Regional Operations Specialist Dan Gormley. A hard copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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 12/16/2022 08:43 AM - 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: TERRAZA COURT
FACILITY NUMBER: 198602264

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
Section Cited

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This was not met as evidenced by:
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LPA instructed S1 to associate himself and S2 to the facility. S3 must obtain a background clearance and associated to the facility prior to working. POC must be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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Based on LPA's review of the Facility Personnel Summary Report, S3 has no background clearance and not associated to the facility. S1 and S2 are not associated to the facility. This poses an immediate heath, safety and/or personal rights risk to residents 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: Stephanie CifuentesTELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2