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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603319
Report Date: 04/14/2023
Date Signed: 05/23/2023 01:37:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
01/14/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220114151554
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: 68DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cesilia Torres-Assistant AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident has unidentified bites on their body whle in care
INVESTIGATION FINDINGS:
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The purpose of this report is to clarify the allegation findings narrative documented in the report created on 5/26/2022. The “Substantiated” findings remain unchanged; however, this report was created on 4/14/23 Supersedes the complaint investigation report created on 5/26/2022.

On 1/19/22 Licensing Program Analyst (LPA) Martessa Brown conducted a 10 day visit regarding the above listed allegations. LPA met with Cesilia Torres, the facility Assistant Administrator and the purpose of the visit was explained. LPA obtained the following documents: LIC 500 and Staff Roster, Residents #1-2 admission agreements, most recent physician reports/appraisals, needs & service, emergency contacts, medication list and records. LPA requested incident reports, pest control invoices for the past 6 months.
On 5/17/22 LPA Brown concducted interviews and on 05/26/22 made a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Bella Naygas the Administrator and the purpose of the visit was explained LPA conducted interviews with the administrator, residents #R2-R7, Staff #1-7.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
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 5
Control Number 11-AS-20220114151554
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 04/14/2023
NARRATIVE
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Regarding the allegation: Resident has unidentified bites on their body while in care

On 5/17/22 LPA interviewed Bells Naygas regarding the above allegation and she stated was not aware of any residents having scabies or bedbugs and pest control comes out to the facility once a month. LPA interviewed staff #1-7, staff stated facility had a problem bedbug and did not have scabies. LPA did not interview R1 due to not being at the facility. LPA interview residents (R2-R7), 2 out of 7 residents stated they had bedbugs in their bedrooms. LPA interviewed Witness (W1) and stated resident R1 was diagnosed with scabies when admitted to the hospital. LPA reviewed hospital records and it was indicated R1 had scabies. During the investigation the administrator did not identify that R1 had scabies and needed to have R1 seen by the doctor. Based on Interviews and documents gathered during this investigation, LPA found sufficient evidence to support that the above-mentioned 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.

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

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20220114151554
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2022
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 and equipment. This requirement was not met as evidenced by:
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Administrator will review the regulation to ensure residents are to accorded safe and healthy conditions. Administrator will send a statement and come up with a plan on how she will ensure residents are provided healthful and comfortable environment. Administrator will provide proof to LPA by 6/1/22.
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Based on observation, interviews conducted and documents. LPA conducted interviews with residents, staff and witness and it was confirmed facility had scabies and bed bugs.

This is a potential health and safety risk to clients 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
01/14/2022 and conducted by Evaluator Martessa Brown
COMPLAINT CONTROL NUMBER: 11-AS-20220114151554

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: 68DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cesilia Torres-Assistant AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
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3
4
5
6
7
8
9
10
11
12
13
The purpose of this report is to clarify the allegation findings narrative documented in the report created on 5/26/22. The “Substantiated” finding have been changed to Unsubstantiated; however, this report was created on 4/14/2023 supersedes the complaint investigation report created on 5/26/22.

On 1/19/22 Licensing Program Analyst (LPA) Martessa Brown conducted a 10-day visit regarding the e above listed allegations. LPA met with Cesilia Torres, the facility Assistant Administrator and the purpose of the visit was explained. LPA obtained the following documents: LIC 500 and Staff Roster, Residents #1-2 admission agreements, most recent physician reports/appraisals, needs & service, emergency contacts, medication list and records. LPA requested incident reports, pest control invoices for the past 6 months.
On 5/17/22 and 5/26/22, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Bella Naygas the Administrator and the purpose of the visit was explained. LPA toured the medication room and reviewed R1-2 medications and logs. LPA conducted interviews with the administrator, residents #R2-R7 and Staff #1-7.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20220114151554
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 04/14/2023
NARRATIVE
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Regarding the allegation: Staff mismanaged resident's medication

On 5/17/22, LPA interviewed Bells Naygas regarding the allegation. She stated R1 has not mismanage R1’s or residents medications. LPA did not interview R1 due to not being at the facility. LPA interviewed residents (R2-R7) and residents stated they have not had their medication mismanaged and receive them on time by the medical technicians. LPA interviewed staff #1-7, staff stated they have not mismanaged R1’s or residents’ medication. LPA reviewed medication storage area and R1’s mars for the time she was at the facility. LPA reviewed R1’s medication log and did not see any discrepancy.

Based on investigation, interviews and documents the above allegation is unsubstantiated.

Although the allegations are valid or may have happened there is insufficient evidence to support the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5