198602264-6-1-2023-11-AS-JHAD-CSY25V-20230619170611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 06/01/2023
Date Signed: 06/01/2023 05:25:52 PM

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
04/04/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230404105721

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: 62	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Jasmine Hazar		TIME COMPLETED:	03:59 PM

ALLEGATION(S):

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Resident eloped from facility without staff knowledge.

INVESTIGATION FINDINGS:

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On 06/01/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit at this facility. LPA was greeted by Executive Director Jasmine Hezar, and explained the purpose of today’s visit is to gather information regarding the allegation mentioned in this complaint.

Investigation consisted of the following: Interviews were conducted with resident #1 (R1), Executive Director and staff #2-#4. A reviews of (R1’s) service records and other pertinent documents assocated with this complaint. Facility areas pertinent to the investigation were inspected: resident bedroom, assisted living, memory care, and hallways inside and outside.

(Evaluation Report continues on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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-20230404105721

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: 06/01/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident eloped from facility without staff knowledge.
On 03/24/23, Executive Director staff #1 (S1) stated on an incident report that resident #1 (R1) had wander off the facility on 03/19/23. (R1) was found outside the facility in the rear of the building and had exited through an emergency stairwell door. (S1) recalled the incident and was immediately notified by staff #4 (S4) at 6:00 am that (R1) had wandered off the premises, unattended and locked out. (S4) then called emergency medical services (EMS), while (S1) contacted the representative of (R1). (S1) claimed to have contacted staff #2 (S2) directly to check on alarms and all emergency exit doors.

As a result of an interview with (R1), (R1) recalls the incident, however (R1) is unable to provide details regarding the means by which (R1) left the facility. Interviews staff #3-#4 (S3-S4) both had arrived for their shift at 6:00 am spotted (R1) outside the facility and was trying to get inside through the underground garage. (S3-S4) verified contacting (S1) and (EMS) immediately. (S3-S4) confirmed that (R1) did not appear to have any injuries and was taken to a nearby hospital for further medical observation. (S2) described the day of the incident, (S2) had received an urgent call from (S1) to check on all the alarms and emergency exit doors. (S2) stated the alarm for the emergency door (R1) had activated was in working condition but was uncertain for why the night shift staff was not alerted through the pager devices. (S4) is certain the alarm door was not operable condition. While (S1) was uncertain if the alarm was in operable condition on 03/19/23. According to (S1-S2) the facility does not have surveillance camera. (S1) claimed there were two agency staff who worked on 03/19/23. The Department was not able to obtain statements from the agency staff. During the visit, the Department tested the emergency alarm system on the exit doors, and they are in operable condition. The Department reached out to the complainant and was unable to obtain further statements on the incident. The information gathered and the acknowledgement of (R1) and (S1-S4) support this allegation.

Based on observations, interviews and record reviews, the preponderance of evidence standard has been met therefore the above allegation is found to be substantiated. California Code of Regulations, Tittle 22 are being cited on (LIC 9099-D).

An exit interview was conducted, with Executive Director Hezar. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230404105721

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: 06/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/02/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	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.. (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to submitted to CCLD by 06/02/23 and a Final Plan of Correction will be submitted to CCLD on or before 06/02/23. Licensee agreed that all staff will be advised to be on "high alert" meaning being more vigilant in monitoring exits while a Plan of Correction is being developed. POC due date: 06/02/23
	8 9 10 11 12 13 14	Based on LPA gather information. Licensee did not ensure the safety of (R1) who wandered out of the facility, went missing, unsupervised by staff. (R1) needs assistance when leaving the facility according to physician's report 12/9/22.This violation poses an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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