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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603319
Report Date: 06/02/2022
Date Signed: 06/02/2022 06:26:21 PM

Substantiated


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
05/10/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220510121555
FACILITY NAME:BEVERLY HILLS TERRACEFACILITY NUMBER:
198603319
ADMINISTRATOR:STRIKS, AHARONFACILITY TYPE:
740
ADDRESS:1470 S ROBERTSON BLVDTELEPHONE:
(310) 273-3668
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:110CENSUS: DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Bella NaygasTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident sustained an injury from a fall while in care.
Regarding allegation: Staff did not properly report an incident regarding a resident.
INVESTIGATION FINDINGS:
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On 6/2/22, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Administrator Bella Naygas and Assistant Administrator Cesilia Torres and explained the purpose of todays visit.

The investigation consisted of the following: On 5/17/22, LPA toured the facility and conducted a health and safety check. LPA obtained the following documents: LIC 500 and Staff Roster, Residents #1-3 admission agreements, most recent physician reports/appraisals, emergency contacts and medication records. LPA conducted interviews with the Administrator and assistant, staff members #1-5 and residents #1-4.

Regarding allegation: Resident sustained an injury from a fall while in care.

On 5/17/22 and 5/27/22, LPA interviewed Bells Naygas regarding the above allegation and she stated
LIC 9099-C is on the next page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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-20220510121555
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: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 06/02/2022
NARRATIVE
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wasn’t aware of any residents sustaining injuries from a fall but later admitted R1 sustained injuries last month and only a bruising. She stated resident did not need to go to the hospital and R1 was seen by home health nurse the following day. LPA interviewed assistant administrator Cesilia Torres and she stated was not aware of any resident falling last month. LPA interviewed staff S1, stated there was no resident that had fell and suffered injuries but later admitted to R1 falling but stated did not see what happened but was informed of the incident. LPA interviewed staff members #2-#5, they stated R1 had fell last month and had suffered bleeding and bruising to face. LPA interview residents #1, stated suffered injuries to face the later part of April. R1 stated was assisted by a caregiver, who was supposed to transport him from the wheelchair to the bed. R1 stated caregiver proceeded to hold up by the shirt and fell onto the bed rails two times and face was injured. R1 stated caregiver kept apologizing and applied ice to face. LPA interviewed residents #2-4, they stated wasn’t aware of a resident falling. LPA obtained copy of the report log and R1 had an eye injury and was bleeding. Based on documents and interviews the above allegation is substantiated.

Regarding allegation: Staff did not properly report an incident regarding a resident.

On 5/17/22 and 5/27/22, LPA interviewed Bells Naygas. She stated they did not complete an incident report for R1. She stated they haven’t done an incident reports in a long time but will start submitting them. LPA interview Cesilia Torres and she stated no incident reports was completed regarding the incident. LPA interviewed staff members # 1-5 and no incident report was made regarding R1. They also stated for incidents that happen they will log in a notbook in the office and will report to staff in charge. LPA observed log book in the office of R1 incident and there was no incident report made. Based on documents and interviews the above allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D and LIC 421 FC-Failure to Correct and Repeat Violation.

Exit interview was conducted and a copy of the report and appeal rights was given to Cesilia Torres..

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20220510121555
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: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings ...
This requirement is not met as evidence by:
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Administrator will review regulation and will train staff. Administrator will also submit a plan on how she will prevent residents from falling while in care to LPA by poc due date.
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Based on observation and interview conducted on 5/17/22 and 5/27/22, Administrator and staff stated R1's sustained and injury and was not taken to the hospital.

This poses an immediate/Potential health & safety risk to residents in care.
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Type B
06/09/2022
Section Cited
CCR
82711(a)(1)
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87211 Reporting Requirement
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days..

This requirement was not met as evidence by:
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Administrator will provided to LPA incident report regarding R1 and will review regulation and train staff on the regulation and how to report incident. Administrator will submit a plan on how they will maintain reporting requirements to LPA by poc due date.
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Based on observation and interview conducted on 5/17/22 and 5/27/22, Administrator and staff did not report to CCLD R1's incident.

This poses an immediate/Potential health & safety risk to 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3