198602264-9-30-2024-11-AS-RORN-DAZUXY-20241114145906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602264
Report Date: 09/30/2024
Date Signed: 09/30/2024 03:43:25 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, 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
09/20/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20240920145746

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: 69	DATE:	09/30/2024
		UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Brittany Kavanaugh, Executive Director		TIME COMPLETED:	03:44 PM

ALLEGATION(S):

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Staff did not properly supervise resident resulting in resident administering another resident’s medication causing hospitalization.

INVESTIGATION FINDINGS:

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On 9/30/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Administrator, Brittany Kavanaugh and explained the purpose of the visit is to investigate the allegation mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:

LPA requested LPA Shirley requested and received copies of the following: Staff Roster, Resident Roster, resident files, MAR’s, SIR’s and Hospitalization list. LPA interviewed S1 thru S7 and C1 thru C7.

The investigation revealed the following:

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

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 3

Control Number 11-AS-20240920145746

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: 09/30/2024

NARRATIVE

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Allegation: Staff did not properly supervise resident resulting in resident administering another resident’s medication causing hospitalization.

It was reported that R-1 may have ingested another resident’s medication while being unsupervised. LPA learned through interviews that R-1 was the only resident observed to be up walking around 9/18/24. S-5 encountered R-1 while she was assisting another resident when R-1 came into the resident’s room appearing out of it as stated by S-5. When S-5 finished attending to current resident she walked R-1 back to their room. As they walked to his room, R-1 began to drool, when they entered the room, R-1 began to vomit. The paramedics and spouse were called. LPA Felisa Shirley reviewed facilities Special Incident Reports and learned that there is no history of residents ingesting another resident’s medications. During file review, LPA Shirley observed the After Visit Summary report from UCLA Health dated 9/18/24 stating that R-1’s diagnosis was nausea and vomiting, unspecified vomiting type. Resident’s evaluation included a physical exam, labs, and imaging, but there was no serious cause of the vomiting found. Through interviews, LPA learned that medications were administered one hour prior to incident and there were no medications around or accessible to clients in care.

LPA interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA ask, does staff supervise residents in order to prevent other residents from ingesting someone else’s medication? Of those interviewed, 6 out of 7 answered yes. One staff did not know. LPA interviewed resident -1 thru resident - 7 (R-1 thru R-7).

Con'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20240920145746

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: 09/30/2024

NARRATIVE

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LPA ask, does staff properly supervise other residents while medications are being administered, to prevent other residents from taking your medications. Of those interviewed, 5 out of 7 answered yes. Two residents stated they don’t take medications. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not properly supervise resident resulting in resident administering another resident’s medication causing hospitalization,” therefore the allegation is unsubstantiated.

There were no deficiencies observed during this visit.

LPA conducted an exit interview and a copy of this report was signed by Administrator, Brittany Kavanaugh.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024

LIC9099 (FAS) - (06/04)

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