198602264-11-1-2023-11-AS-WGIS-CX73BC-20231101180607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602264
Report Date: 11/01/2023
Date Signed: 11/01/2023 06:06:18 PM

Document Has Been Signed on 11/01/2023 06:06 PM - 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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: 59	DATE:	11/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jasmine Hezar		TIME COMPLETED:	04:45 PM

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	On 11/01/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the full CAREs tool. LPA met with Administrator, Jasmine Hezar, and the purpose of this visit was explained. The facility is licensed for 115 non-ambulatory, four of which may be bedridden, age 60 and over. The facility has an approved hospice waiver for 10. The facility is approved for a delayed egress exiting on the second floor, and a waiver granted for a secured perimeter. Currently there are 59 residents residing at the facility. Structure/Physical Plant LPA toured the facility with Administrator. The facility is a three-story commercial building. The facility consists of the following: The first-floor Lobby/receptionist area, Executive Director's office, Business office, copy area, Marketing office, living room, library/activity room, cafe/bistro/latte/water area, public/visitor restrooms, hair salon, life enrichment/activity office, storage rooms, dining room, commercial kitchen, staff restrooms, commercial laundry room, resident's laundry room, Director of Nursing office, medication room, employee's lounge, emergency food, mechanical room, electrical room, 3 storage rooms, and attached underground security parking garage. The second floor consists of resident's bedrooms and bathrooms, storage closets, and patio. The Memory Care Unit (MCU) consists of bedrooms and bathrooms, resident's laundry room, dining room/activity room, small kitchen, living room/TV room, shower room, Memory Care Coordinator office, small living room, storage room, and MCU patio. The third floor consisted of bedrooms and bathrooms, resident's laundry room, small living room/TV room. Bedrooms LPA inspected 8 resident rooms that were observed to be clean and in good repair. All rooms were observed to have the required furnishings including a bed, dresser, nightstand, chair, and ample storage space for personal belongings. Residents furnish their rooms, but there is furniture available if needed. All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. All rooms were observed to have ample lighting. Bathrooms All bathrooms inspected were observed to be clean and operational. All showers had secure safety handrails, non-skid mats, and/or a shower chair. The water temperature measured between 114.5-degrees and 116.8-degrees Fahrenheit. Continued on LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA COURT	FACILITY NUMBER: 198602264
	VISIT DATE: 11/01/2023

NARRATIVE

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Kitchen LPA inspected the commercial kitchen and found it to be clean and sanitary. LPA observed an ample supply of kitchenware, dishware, and cutleries to be in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All food was observed to be stored, packaged, and labeled properly. LPA observed an ample supply of emergency food and water in a storage room. LPA observed the weekly menu posted on the dining room door. All appliances were observed to be operational and in good repair.
Common Rooms LPA observed all common rooms. All rooms had ample seating to accommodate residents. All walkways and hallways were observed to be clean, clear, free of obstructions and hazards. All rooms were observed to have ample lighting. LPA observed activity scheduled on the wall by the dining room. Residents were involved in a group exercise activity in the library/activity room when LPA arrived. The facility was maintained at a comfortable temperature.
Safety All fire and carbon monoxide detectors were in compliance and operational. LPA observed fire extinguishers to be fully charged and last serviced on 11/21/22. The last fire inspection and sprinkler system service by the local fire department was on 05/16/23. The last emergency drill was conducted on 09/23/23 and 09/24/23. LPA inspected the First Aid Kit and found it contained the required items and a manual. All emergency pull cords are operable. The facility has a working landline telephone. All exits are clearly marked. LPA observed all required posting in the facility.
File Review/Interviews LPA reviewed 6 resident file and found they contained the required items. LPA interviewed 6 residents, and all were happy with the care and services they receive at the facility. LPA reviewed the Administrator and 4 staff files and found they contained the required documents, training, and certification. LPA interviewed 5 staff, and all were able to explain policy, procedure, and resident care and personal rights.
Medications LPA observed all Centrally Stored Medications secured in the medication room and inaccessible to residents. LPA reviewed the medications and MAR for 6 residents. All resident’s MARs and medication are consistent with properly documented records.
Infection Control LPA observed a sanitizing station at the facility receptionist area front entrance; visitors log with COVID-19 screening and temperature log. PPE supplies are readily available to staff, and an additional over 90-day supply of PPE is stored in the storage closet; sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed all required infection control posters posted throughout the facility.

LPA did not observe or cite any deficiencies.

LPA conducted an exit interview with administrator Jasmine Hezar, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023

LIC809 (FAS) - (06/04)

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