198602264-12-28-2023-11-AS-EMAZ-CZU4VC-20240125182608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 12/28/2023
Date Signed: 12/28/2023 02:58:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
12/22/2023 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20231222133813

FACILITY NAME:	TERRAZA COURT		FACILITY NUMBER:	198602264
ADMINISTRATOR:	HEZAR, JASMINE		FACILITY TYPE:	740
ADDRESS:	10955 WASHINGTON BLVD		TELEPHONE:	(310) 838-7800
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	170	CENSUS: 59	DATE:	12/28/2023
		UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	ADMINISTRATOR JASMINE HEZAR		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Lack of supervision resulting in resident found on the ground.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Terraza Court facility on 12/28/2023 at around 09:00 AM and was greeted by Administrator Jasmine Hezar (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

Investigation consisted of the following: LPA Calderon interviewed Jasmine Hezar A1, S1-S3, R1-R7. These interviews were conducted on 12/28/2023. LPA Calderon obtained and reviewed the following: Physician Report (dated 02/07/2023), Physician communication report (date 11/04/2023), Incident report (date 11/04/2023 and 12/19/2023) for R1.

The investigation revealed the following

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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-20231222133813

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/28/2023

NARRATIVE

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Regarding Allegation #1: Lack of supervision resulting in resident found on the ground.

This complaint alleged that due to lack of supervision R1 was found on the ground. LPA Calderon conducted an interview with A1. A1 states that R1 has been living at the facility for 8 months. A1 states that R1 was found by staff on the floor in R1 room. A1 states that R1 is non-ambulatory and needs help with medication, help with showering. A1 states that staff check on R1 many times and this is how they found R1 on the floor. A1 states that R1 did not fall due to lack of supervision and there are no staffing issues. LPA Calderon conducted an interview with S1-S3. 3 out of 3 staff state that R1 fell and was taken to the hospital for evaluation and was not injured. 3 out of 3 staff state that there are no staffing issues and R1 fall was not caused by lack of supervision. 3 out of 3 staff state that R1 is checked every day and services are given to R1 and all residents. LPA Calderon conducted an interview with R1-R7. R1 states that R1 was getting out of bed 2 or 3 weeks ago. R1 states that R1 lost balance and fell to the floor. R1 states that R1 was not injured, and staff came to help R1 off the floor. R1 states that R1 fall did not happen due to lack of supervision and R1 does not believe there are any staffing issues. 6 out of 6 residents state that there are no staffing issues. 6 out of 6 residents state that residents falling is not due to lack of supervision. R7 states that R7 did not see if R1 fall was due to lack of supervision or not. R7 states that there is staffing issues and R7 has a hard time getting medical services. LPA Calderon reviewed physician report (date 02/07/2023) for R1. Physician report states that R1 is frail and non-ambulatory. Reviewed incident report (date 11/04/2023 and 12/19/2023) for R1. Incident report state that on both incident reports R1 fell to the floor and 911 was called. Report state that staff came to R1 aid, and no injuries were reported by the hospital or staff.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “Lack of supervision resulting in resident found on the ground” is found to be UNSUBSTANTIATED.

An exit interview was conducted and copy of the Complaint Report was provided to the Administrator Jasmine Hezar (A1)

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

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