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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602264
Report Date: 09/13/2024
Date Signed: 09/13/2024 01:51:46 PM


Document Has Been Signed on 09/13/2024 01:51 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 COURTFACILITY NUMBER:
198602264
ADMINISTRATOR:HEZAR, JASMINEFACILITY TYPE:
740
ADDRESS:10955 WASHINGTON BLVDTELEPHONE:
(310) 838-7800
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:170CENSUS: 65DATE:
09/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Wellness Director Michelle BrownTIME COMPLETED:
02:15 PM
NARRATIVE
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On 09/13/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced subsequent complaint (11-AS-20240911085425) visit. LPA meet with the Wellness Director Michelle Brown and explained the purpose of the visit.
During the facility tour, LPA Cloyd observed one out of five thermostats on the second floor near room 237 not working. The second floor thermostats also control the hallway temperatures on the first floor -- including Memory Care. The Facility Manager informed LPA Cloyd that he has the parts now and that the thermostat would be repaired soon.

Deficiencies are being cited according to California Code of Regulation Tittle 22, Division 6 Chapter 8 (see LIC 809D).

Exit interview was conduct, plans of correction developed, and a copy of this report and appeal rights was discussed and provided to the Wellness Director Michelle Brown.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
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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Document Has Been Signed on 09/13/2024 01:51 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The Executive Director will ensure that the facility, including thermostates, remain in good repair at all times. The Executive Director will email proof of correction to regina.cloyd@dss.ca.gov by the POC due date.
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This requirement was not met as evidence by:
Based on observation and interview, LPA observed one non-operable thermostat (near room 237) on the second floor. This poses a potential risk to health and safety of residents in care.
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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: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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