198602264-7-26-2023-11-AS-MVAO-CWXMLY-20231025094308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 07/26/2023
Date Signed: 07/26/2023 10:41:58 AM

Unsubstantiated

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
11/02/2022 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221102124726

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: 67	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Staff #6 (S6: Shelah Smith, Marketing Director) & Staff #7 (S7: LVN Senad Kapetanobic, Resident Services Director).		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident was left soiled while in care.
Staff did not follow physician's orders.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #6 (S6: Shelah Smith, Marketing Director) as the new Administrator (A2: Jasmine Hezar) was unavailable. LPA/RA conducted a risk assessment prior to entering facility. S6 informed LPA/RA that the facility has no COVID cases nor do the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver findings pertaining to the above-mentioned allegations.

An initial 10-Day visit was conducted by LPA Martessa Brown on 11/07/22 with (then) Administrator (A1: Stephanie Funderburg). During the visit, LPA interviewed Administrator, staff members (S2-S5), and residents (R1-R6). LPA reviewed and obtained copies of the following documents: Training records for S1-S3, incident reports, R1 and R2’s admission agreement, Physician’s Report, Needs/Appraisal and Services plan, physician’s orders, Emergency ID Contact Information, medication administration records, facility staff and residents’ rosters.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

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-20221102124726

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: 07/26/2023

NARRATIVE

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Regarding Allegation #1: this investigation revealed based on interviews conducted by LPA Brown of facility staff, five (5) of the five (5) corroborated that they have a list of the residents that need changes; and as the changes are completed, they are marked off the list by initials. No one has missed changes but there are times that a resident(s) will refuse and ask staff to come back later, but no resident has complained about being left soiled while in care. LPA Brown interviewed residents (R1-R6) regarding the allegation and six (6) out of six (6) corroborated that staff did not leave them soiled while in care. A review of Resident #1’s "Physician’s Report" (dated 12/07/18) documented under, “Physical Health Status” that the resident does not have a bowel or bladder impairment. A review of the “Resident’s Assessment” (dated 11/08/22) documented Resident #1 is independent with toileting.

Based on the evidence gathered and interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Resident was left soiled while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on the "Physician’s Report" (dated 12/07/18) documented under “Medication Management” (dated 12/07/18) that Resident #1 can administer and store own medications. A review of Resident #1’s “Physician’s Orders” (as of 11/08/22) of prescribed medications, were administered and documented according to the resident’s medication administration records (October 2022-November 2022). A review of facility staffs medication training documented the course was received on 04/30/22. LPA interviewed facility staff, five (5) of the five (5) corroborated that they have not received a complaint from a resident(s) regarding their physician's orders were not being followed. LPA Brown interviewed residents (R1-R6) regarding the allegation and six (6) out of six (6) corroborated that they did not have an issue with their physician's orders or medication administration.

Based on the evidence gathered and interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff did not follow physician’s orders is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Staff #7 (S7: LVN Senad Kapetanobic, Resident Services Director).

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

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