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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 04/25/2024
Date Signed: 04/25/2024 03:39:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2023 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20230327090547
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:170CENSUS: 66DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Executive Director Jasmine HezarTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff do not ensure that adequate supervision is provided to residents in care.
INVESTIGATION FINDINGS:
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On 04/25/24, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent unannounced visit to the facility and was greeted by Jasmine Hezar, Executive Director. LPA explained the purpose of this visit is to deliver findings for the allegations mentioned above.

The details of the complaint alleged that the facility did not provide adequate supervision of resident in care to prevent injuries sustained in care on 03/25/23. On 04/10/24, from 10:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R8) regarding the allegation. R1 could not be interviewed because R1 is no longer in the facility and is in the hospital. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not ensure that adequate supervision is provided to residents in care. S1-S5 stated that residents are monitored throughout the day to make sure their well-being is taken care of and received regular supervised attention. However, LPA observed that R1 sustained unexplained bruises while in care, and not definitively explained by staff of the circumstances of the bruises of the resident while in care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 11-AS-20230327090547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: TERRAZA COURT
FACILITY NUMBER: 198602264
VISIT DATE: 04/25/2024
NARRATIVE
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LPA interviewed R1-R8 about the allegation and 6 of 8 residents that were interviewed corroborated the allegation that the Staff do not ensure that adequate supervision is provided to residents in care. 6 of 8 residents stated that they are not provided adequate supervision to ensure their well-being is properly ensured while in care.

Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation: Staff do not ensure that adequate supervision is provided to residents in care, are found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D.

Deficiencies are issued and plans of corrections were discussed.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared.

An exit interview was conducted with Jasmine Hezar, Executive Director, appeal rights explained, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20230327090547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TERRAZA COURT
FACILITY NUMBER: 198602264
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2024
Section Cited
CCR
87468.2(4)
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Additional Personal Rights of Residents in Privately Operated Facilities
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The administrator will ensure that all residents are accorded dignity in their personal relationships with staff, residents, and other persons. Facility to conduct in-service training on providing supervision appropriately to keep
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This requirement was not met as evidence by:
Resident sustained bruises while in care of the facility.
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residents safe from abusive behavior from other staff and submit signed log of those who attended trainings and email a copy of the trainings to LPA at perry.scott@dss.ca.gov by POC due date of 05/09/24.
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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: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2023 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20230327090547

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:170CENSUS: 66DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Executive Director Jasmine HezarTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Residents sustained unexplained bruises while in care.
Staff do not ensure resident is receiving bathing assistance.
Staff did not ensure emergency services were contacted in a timely manner.
INVESTIGATION FINDINGS:
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On 04/25/24, Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent unannounced visit to the facility and was greeted by Jasmine Hezar, Executive Director. LPA explained the purpose of this visit is to deliver findings for the allegations mentioned above.

The investigation consisted of the following: An initial complaint visit was completed by LPA Jeremiah Randle on 04/06/2023. A subsequent visit was completed by LPA Perry Scott on 04/10/2024. LPAs investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R8). Resident/Staff Roster, Admission Agreement, Needs and Service Plan, Face sheets/ID and Emergency Information, Pre-Appraisal, Physician's Report, and SIR’s for R1 were obtained from the facility.

The investigation revealed the following: Allegation #1 Residents sustained unexplained bruises while in care.
The details of the complaint alleged that R1 sustained unexplained bruises while in the care of the facility. It was reported that staff stated R1 fell out of bed and hit the right side of R1’s face on the nightstand.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20230327090547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: TERRAZA COURT
FACILITY NUMBER: 198602264
VISIT DATE: 04/25/2024
NARRATIVE
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It is reported that R1 sleeps on R1’s back and would have hit the left side of the table because it is on the left side of the bed. On 04/10/2024 from 10:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R8) regarding the allegation. R1 could not be interviewed because R1 is no longer in the facility and is in the hospital. However, a family member of R1 was interviewed. 1 of 5 staff confirmed the allegation that Residents sustained unexplained bruises while in care, while the other four (S2-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1 stated that the resident was used to lying on their side when sleeping and may have fallen out of the bed and hit their eye during the night causing injury. LPA reviewed an incident report (SIR) and submitted on 03/28/23, that suggests resident may have hit their head on the side of the table during the night. In the report, when ED911 asked resident what happened, R1 stated “something hit it”.

During a record review, LPA reviewed witness statements and photos of R1, three (3) staff members state they discovered R1 with bruises on R1’s eye and the eye was swollen but when staff completed their rounds early in the night R1 was fine. Staff could only speculate that R1 hit their head on the nightstand while falling out of bed in the night. LPA interviewed R1-R8 about the allegation that the Residents sustained unexplained bruises while in care. 6 of 8 residents that were interviewed stated that the facility does not regularly check up on them throughout the night to check on their well-being, while the other two stated that the staff checks on them often.

Based on interviews conducted, records and photos reviewed, there is insufficient evidence to support the allegation that Residents sustained unexplained bruises while in care. 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.

Allegation # 2- Staff do not ensure resident is receiving bathing assistance.

The details of the complaint alleged that the facility did not bathe the resident properly because when the resident was admitted to the hospital for unexplained bruises, the resident had a foul smell, allegedly, as reported by attending nurses, according to reports in the complaint. On 04/10/24, from 10:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R8) regarding the allegation. R1 could not be interviewed because R1 is no longer in the facility and is in the hospital. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff do not ensure resident is receiving bathing assistance. All staff (S1-S5) stated that all residents are bathed and groomed at least twice a week, and according to their care plane, and that they were not negligent in their duties as it pertains to R1 or other

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20230327090547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: TERRAZA COURT
FACILITY NUMBER: 198602264
VISIT DATE: 04/25/2024
NARRATIVE
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residents. LPA interviewed R1-R8 about the allegation and 7 of 8 residents that were interviewed denied the allegation that Staff do not ensure resident is receiving bathing assistance. Residents stated that they are given personal care as needed and are satisfied with the care and supervision given by the staff.

Based on interviews, there is insufficient evidence to support the allegation that Staff do not ensure resident is receiving bathing assistance. 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.

Allegation # 3- Staff did not ensure emergency services were contacted in a timely manner.

The details of the complaint alleged that the facility did not call emergency services or submit an incident report about R1’s injuries, until told to do so, as it was reported in the complaint. On 04/10/24, from 10:30am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R8) regarding the allegation. R1 could not be interviewed because R1 is no longer in the facility and is in the hospital. However, a family member of R1 was interviewed. 5 of 5 staff denied the allegation that Staff did not ensure emergency services were contacted in a timely manner. All staff stated (S1-S5) that whenever there is an emergency with a resident that requires emergency assistance, that can’t be taken care of in the facility, it is promptly reported to the required authorities and 911 to get assistance for the resident in a timely manner. When it was discovered, according to staff of the injuries of the resident R1, they called 911 for assistance and transported the resident to a hospital to access the residents’ injuries and get them care and supervision. LPA reviewed the incident report (SIR) and observed it was reported in a timely manner.

LPA interviewed R1-R8 about the allegation and 7 of 8 residents that were interviewed denied the allegation that the Staff did not ensure emergency services were contacted in a timely manner. Residents stated that the staff are responsive and seek medical attention for them if they have injured themselves and take appropriate measures to get them help.

Based on interviews, there is insufficient evidence to support the allegation that Staff did not ensure emergency services were contacted in a timely manner. 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.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6