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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 12/13/2022
Date Signed: 12/15/2022 08:41:01 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
12/08/2022 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20221208160717
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
UNANNOUNCEDTIME BEGAN:
10:33 AM
MET WITH:DAN GORMLEYTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Toxic chemical was accessible to resident in care
INVESTIGATION FINDINGS:
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On 12/13/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced 10-day complaint visit at this facility. Upon arrival, LPA called the facility to conduct a risk assessment. LPA spoke with Canarie Ford/Medication Technician who confirmed the facility has one employee tested positive with Covid-19. LPA met with Regional Operations Specialist (ROS) Dan Gormley and explained the purpose of today's visit.

The investigation consisted of the following: LPA toured the inside and outside grounds of the facility with ROS Dan Gormley. LPA interviewed five staff (S1- S5) and made an attempt to interview one staff (S6); interviewed one resident (R1) and a witness (W1). LPA requested and obtained copies of the Staff Roster, Resident Roster, Dementia Plan and Resident #1’s service records: Identification and Emergency Information, Admission Agreements, Physician’s Reports, Hospital Records, Appraisal/Needs and Services Plan, and Incident Reports.

Report continued in LIC 9099C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20221208160717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/13/2022
NARRATIVE
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The Investigation Revealed the Following:

Allegation: Toxic chemical was accessible to resident in care.

It is alleged that toxic chemical was accessible to resident in care. Reporting Party stated Resident #1 (R1) was brought to the hospital with a suspicion that R1 had ingested a toxic chemical (Fabuloso) at the facility.

Based on record review, R1 was admitted to the facility on 2/24/2014. R1 has dementia and she is residing in the memory lane of the facility. R1's hospital "After Visit Summary" dated 12/9/2022 indicates R1 was evaluated for possible caustic ingestion. The result shows no certainty that no ingestion occurred but R1 shows no signs or symptoms of caustic ingestion.

Based on interviews conducted, R1 admitted to accessing a toxic chemical (Fabuloso) and attempted to drink from the bottle. Interview with a witness (W1) and four staff (S1-S4) revealed R1 had access to a toxic chemical called Fabuloso. S1, S3 and S4 stated R1 was found walking in the memory lane hallway holding a bottle of Fabuloso. S4 stated on 12/8/2022 at around 11:30 am, she witnessed R1 holding an open bottle of Fabuloso attempting to drink from it. S4 stated she immediately took the bottle and reported the incident to S3. S3 stated she called 911 and R1 was taken to the hospital for a suspicion that R1 drank the Fabuloso. S1 stated R1 was discharged from the hospital and returned to the facility the next day.

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.)

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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20221208160717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87705(f)(2)
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(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement was not met as evidenced by:
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Regional Operations Specialist Dan Gormley provided LPA with a copy of in-service regarding Section 87705 of Title 22. The facility purchased a cart with a lock for housekeepers to ensure residents can't access the cleaning supplies. This deficiency was corrected during the visit.
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Based on interviews conducted, R1 admitted to accessing a toxic chemical (Fabuloso) and attempted to drink from the bottle. Interview with a witness (W1) and four staff (S1-S4) revealed R1 had access to a toxic chemical called Fabuloso. S4 stated on 12/8/2022 at around 11:30 am, she witnessed R1 holding an open bottle of Fabuloso attempting to drink from it.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3