198602264-7-22-2023-11-AS-JHAD-CZLRN4-20240118120942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 07/21/2023
Date Signed: 07/22/2023 03:41:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/09/2023 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230509155024

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: 68	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Jasmine Hezar, Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff assaulted resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Jasmine Hezar, Executive Director.

The investigation consisted of following: Interviews and Record reviews. On LPA Soto interviewed S#1 - Executive Director & R#1. The LPA also requested copies of the following documents: R#1 file (ID/Emergency information, medication list, Physician's report, hospital medical record, Admission agreement, and Dual POA, Files for S#2 - S#4 (personnel record, application, work duties, and trainings, Incident pictures and videos, and Incident written statements from staff and R#1. On 07/13/23, LPA Soto interviewed S#1-Executive Director, S#2, S#3, S#4 -via telephone. LPA attempted to interview S#5-S#7 via telephone. LPA left v/m message and sent text to S#5. S#6, phone number was no longer in service. S#7, phone was turned off.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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-20230509155024

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA COURT	FACILITY NUMBER: 198602264
	VISIT DATE: 07/21/2023

NARRATIVE

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LPA also interviewed R#2 - R#6. LPA obtained the following documents: Resident and Staff rosters, Copy of additional staff statements. On 07/17/23, LPA interviewed S#5 – via telephone. S#8, LPA attempted to interview staff, LPA left v/m message and S#8 never returned LPA’s call. S#9, LPA attempted to interview staff via phone, phone was disconnected.

Based on the LPA's investigation, the investigation revealed the following. Allegation – Staff assaulted resident in care. Interviews with S#1-S#4, communicated that they did not witness the incident where R#1 was allegedly assaulted by staff. They were not working during the night shift, they just heard about the incident . LPA made several attempts to interview S#6 – S#9, their phones were either turned off, no longer in service, or LPA left voice mail and staff never returned LPA’s call. S#6 – S#8, were the staff that allegedly were involved in the assault on R#1, they no longer work at the facility, including S#9. S#3 & S#4, communicated that they overheard a conversation S#9 was having over the phone. S#9 had their phone on speaker, they did not know who S#9 was speaking with, but they did know it was a staff member. The unknown staff member on the line commented something like, “You saw his face, I did that.” But they could not identify who the staff member was, but they believed it was S#7, but cannot confirm it, S#9 never mentioned the unknown staff member name. The facility does not have cameras in the facility, so there is no video evidence as to the alleged assault. Interview conducted with R#1, communicated that R#1 was dragged by staff, but did not identify who the staff members were. R#1 left 2 written notes in his room, where she states that he was assaulted and dragged by staff, but did not identify staff in the letter either. Interview conducted with R#2, communicated that they have never been assaulted or miss treated by any staff. The staff is very helpful and nice. R#3 - R#6, residents could not communicate with LPA. The interviews conducted did not concur with the above allegation.

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 is unsubstantiated.

An exit interview was conducted with Jasmine Hezar, Executive Director, and a hard copy of report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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