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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603319
Report Date: 05/17/2021
Date Signed: 05/18/2021 09:15:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BEVERLY HILLS TERRACEFACILITY NUMBER:
198603319
ADMINISTRATOR:STRIKS, AHARONFACILITY TYPE:
740
ADDRESS:1470 S ROBERTSON BLVDTELEPHONE:
(818) 293-2007
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:110CENSUS: 76DATE:
05/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Clifford Johnson, Assistant AdministratorTIME COMPLETED:
12:00 PM
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On 05/17/2021 around 11:00am Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Case Management – Incident to conduct a Health & Safety check and follow-up on an incident reported to Community Care Licensing (CCL). During today’s visit LPA met with Clifford Johnson and the purpose of the visit was explained. On 5/14/21, CCL received an incident report regarding Resident #1. According to the incident report R1 jumped off a freeway overpass and is now deceased.

During today’s visit LPA toured facility's physical Plant. The tour consisted of a 3--story building, all common areas which included but were not limited to; building entrances, reception areas, office, hallways, public restrooms, dining room, kitchen, pantry, medication storage and patio area. LPA also reviewed the facility's entry procedures, body temperature monitoring practices, social distancing practices, protective facial covering practices and disinfection/sanitation practices.

LPA requested copies of the staff and resident rosters along with a copy of the following from Resident #1 facility's record by 5/19/2021.
· Pre-Placement Appraisal’s
· Admission Agreement
· Identification and Emergency Information's
· Reappraisals
· Needs and Services Plans
· Behavior assessments
· Physicians Reports
· Medication Logs
· Incident Reports
· Progress Notes
· Hospital discharge notes
· Death Certificate

Due to insufficient information further investigation is needed.

A telephonic exit interview was conducted with administrator and a hard copy was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021
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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