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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602264
Report Date: 08/03/2023
Date Signed: 08/03/2023 11:53:47 AM


Document Has Been Signed on 08/03/2023 11:53 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: 67DATE:
08/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Jasmin Hezar/Executive DirectorTIME COMPLETED:
11:53 AM
NARRATIVE
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On 08/03/23, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management Deficiencies visit at this facility. LPA met with Jasmin Hezar/Executive Director and explained the purpose of the visit.


On 4/4/23 RO (Regional Office) received a complaint regarding a resident eloping from facility, an investigation was conducted, and citations were rendered on 6/1/23. On 8/2/23 OD (Office on Duty) received an SIR (Special Incident Report) regarding R1 eloping from facility on 8/1/23. Resident is from memory care; he was found after a few minutes after resident eloped from facility.


Civil Penalty Assessed.
Deficiencies cited under California Code of Regulation Tittle 22, Division 6 Chapter 8 are being cited on the attached LIC 809D.

Exit interview conduct, appeal rights discussed and a copy of this report and appeal rights provided.

An exit interview is conducted with Executive Director and a copy of this report was provided to her.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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 08/03/2023 11:53 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: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2023
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.. (2) To be accorded safe, healthful and comfortable accommodations...
This requirement was not met as evidenced by:
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Licensee agrees to submitted to CCLD by 08/04/23 an immediate Plan of Correction advising all staff to be on "high alert" meaning being more vigilant in monitoring exits in the dementia unit. A comprehensive final Plan of Correction will be submitted to CCLD on or by 08/07/23. This plan includes that all staff will be trained on how to provide care to people with dementia. Copy of the training and signing sheet will be email to LPA by POC due date.
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(R1) who wandered out of the facility unsupervised by staff. (R1) must have an escort at all times when leaving the community according to physician's report 5/16/2023.This violation poses an immediate health and safety risk to clients in care. This violation poses an immediate health and safety risk to clients 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2