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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603319
Report Date: 02/06/2025
Date Signed: 02/06/2025 04:50:30 PM

Document Has Been Signed on 02/06/2025 04:50 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:BEVERLY HILLS TERRACEFACILITY NUMBER:
198603319
ADMINISTRATOR/
DIRECTOR:		STRIKS, AHARONFACILITY TYPE:
740
ADDRESS:1470 S ROBERTSON BLVDTELEPHONE:
(310) 273-3668
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY: 110CENSUS: 61DATE:
02/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:28 PM
MET WITH:Yesenia RoblesTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 02/06/2025, Community Care Licensing Division (CCLD) Staff conducted a case management visit at the above facility and met with Staff Yesenia Robles. The purpose of the visit was to investigate complaint #11-AS-20250128170803. During the facility tour, CCLD Staff observed two damaged doorknobs for Resident #1 and Resident #2. Resident #1 (R1) is unable to lock R1's door when exiting the room.

Deficiencies were issued (see LIC809-D).

An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with Staff Yeenia Robles.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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 02/06/2025 04:50 PM - It Cannot Be Edited


Created By: Regina Cloyd On 02/06/2025 at 04:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/18/2025
Section Cited
CCR
87303(a)

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Maintenance and Operation. 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...
This requirement was not met as evidence by:
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The Licensee will repair Resident #1 and #2's doorknobs and email evidence to regina.cloyd@dss.ca.gov by the POC due date.
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Based on observation, CCLD Staff did not observe Resident #1' and #2's doorknob to be in good repair which poses a potential safety risk for 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 Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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