198602264-6-29-2023-11-AS-EMAZ-CTWLJ2-20230720084712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 06/29/2023
Date Signed: 06/29/2023 04:11:59 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
06/23/2023 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20230623161343

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: 69	DATE:	06/29/2023
		UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	Jasmine Hezar-Executive Director		TIME COMPLETED:	04:11 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mismanaged a resident's medication

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 6/29/2023 LPA Alfonso Iniguez conducted and unannounced complaint visit. LPA Iniguez meet with Jasmine Hezar/Executive Director. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted interviews with Resident (R#1-R#6), Administrator(A#1), and Staff (S#1-S#6) and Reporting Party (RP). LPA obtained and reviewed R#1-R#4 Physician Report date:1/27/2023, R#1-R#4 Medication Administration Record June 2023, R#1-R#4 Needs and Services Plan dated:3 /2/2021, R#1-R#4 Admissions Agreement Date: 2/3/2020 and R#1-R#4 Emergency ID information.

Evaluation Report Continues on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

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-20230623161343

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: 06/29/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff mismanaged a resident's medication
It is alleged that on 6/22/2023, Resident R#1 was administered the incorrect medications. LPA reviewed the Medication Administration Records (MAR) for June 2023, and found a notation on 6/22/2023, stating “wrong medication given” during the 10:00 am medication rounds. LPA conducted an interview with the Administrator/ Jasmine Hezar (A#1), who stated on 6/22/2023 A#1 was informed by the facility Charge Nurse that the incorrect medications were administered to R#1 during the early-day medications rounds. A#1 stated the incorrect medication was to R#1 administered by Med Tech S#1. S#1 called the supervising LVN and 911 immediately after administering the incorrect medications. When Emergency Medical Services arrived, R#1 refused to be taken to the hospital. EMS conducted an assessment to rule out a medication overdose and allowed R#1 to remain at the facility. R#1’s medical provider was then contacted and was then monitored by caregivers for a 48-hour period for signs of a possible medication reaction. LPA conducted an interview with R#1 who stated the incorrect medication was administered to R#1 on 6/22/2023. R#1 stated that illness from the incorrect medication did not occur, and caregivers monitored R#1 closely after the incident. LPA conducted interviews with residents R#2-R#6 and 5 of 5 Residents expressed not having experienced medication errors. LPA conducted interview with S#1 who stated that S#1 administered the incorrect medication to R#1 on 6/22/2023. LPA conducted interviews with Staff (S#2-S#6) and 5 out of 5 staff members expressed having knowledge of the incorrect medication that was administered to R#1 on 6/22/2023. Based interviews conducted and a review of records, LPA found sufficient evidence to support the above mentioned allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were given to Jazmin Hezar/Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230623161343

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: 06/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/17/2023 Section Cited CCR 80075(b)	1 2 3 4 5 6 7	The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will ensure staff will get re-trained on how to handle medications appropiatley. A copy of the staff training will be sent to LPA via email before POC due date.
	8 9 10 11 12 13 14	Based on the LPA's interviews, and record review, facility staff members facility failed to manage R#1 medication correctly.	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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3