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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603319
Report Date: 12/18/2025
Date Signed: 12/18/2025 10:01:41 AM

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
03/24/2025 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250324094301
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: 58DATE:
12/18/2025
UNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:ELLA NAYGAS -ADMINISTRATORTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff did not prevent a resident from developing pressure injuries.
Staff do not ensure that residents' dietary needs are met.
Staff do not observe residents for change in condition.
Staff did not assist resident with grooming.
Staff do not maintain facility sanitary.
INVESTIGATION FINDINGS:
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**This report supersedes the previous report created on 10/17/2025 to correct and clarify findings. **

On 12/18/2025 at approximately 08:06 AM, Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to re-deliver findings to the facility listed above. LPA Watson met with the administrator Ella Nayagas, and the purpose of today’s visit was explained. LPA was given access to the facility.

The investigation consisted of the following

On 10/16/2025 between 10:20 AM – 04:58 PM, the department requested, reviewed, and obtained copies of the Staff Roster (08/01/2025) and Resident Roster (10/11/25).

CONTINUED ON LIC9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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 6
Control Number 11-AS-20250324094301
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: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 12/18/2025
NARRATIVE
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On 10/17/2025 at approximately 08:48 AM, the department requested and obtained the following documentation: Admission Agreement, Physician’s Report (01/20/25), Appraisal Needs and Services (10/02/2024), and Monthly Menu Plan, Staff Log Notes (01/04/25) and Medical Records (02/01/25-03/29/25). On 10/16/2025 at approximately 10:20 AM, the department conducted interviews with Staff #1-#5 (S1-S5), Beverly Hills Home Health Care/LVN (W1) and Residents #2-#7 (R2-R7).

The investigation revealed the following:

Allegation: Staff did not prevent a resident from developing pressure injuries.



This complaint is alleging that R1 sustained pressure injuries on the backside of their body and was hospitalized with these injuries on 3/18/25. The department conducted an interview with the Administrator/ Bella Naygas, Staff #1 (S1), the Administrator, S1, who stated that the facility provided meals to Resident #1 (R1) over a two day period 03/16/25 - 03/18/25. During this time, R1 consistently refused both food and fluids. In response, to R1 not eating the staff offered Ensure as a nutritional supplement, but R1 also refused that. On the second day that R1 declined food, including Ensure, the facility arranged for him to be transferred to So Cal Culver City Hospital. Following his transfer to hospital R1 did not return to the facility after discharge. S1 stated R1 did not sustain pressure injuries while in care. Staff #1 (S1) stated that residents are monitored closely daily, for changes in skin conditions and caregivers report any changes. The department conducted an interview with the Beverly Hills Home Health Care Nurse /LVN (W1) revealed that she visits the facility between 8:00 AM – 11:00 AM, seven days per week, and assists R1 as well as other facility residents. The LVN stated repositioning residents, hygiene needs, skin injuries and infection prevention are part of ongoing staff training. The department obtained and reviewed R1’s medical records from So Cal Culver City Hospital and found R1 was admitted for lethargy and dehydration from 3/18/25-3/25/25. The department was unable to find evidence of R1 having sustained pressure injuries on the backside of their body. Additionally, the hospital records reflected skin assessments were conducted daily while R1 was hospitalized. On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7). The department asked the residents if staff neglected to prevent them from developing pressure injuries. Of those interviewed, 6 out of 6 residents denied the allegation. An attempt to interview Resident #1 (R1) was made; however, R1 was hospitalized at the time of the visit and could not be interviewed via telephone.
CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20250324094301
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: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 12/18/2025
NARRATIVE
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On 10/16/2025, the department interviewed Staff #1–#6 (S1–S6) and found 6 out of 6 staff denied the allegation Staff did not prevent R1 from developing a pressure injury.
Based on records, observations, interviews conducted, and an analysis of evidence gathered, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated.

Allegation: Staff do not ensure that residents’ dietary needs are met.

This complaint is alleging R1 was malnourished at the facility and that “all of the residents" at the facility, appeared to be underweight. The department conducted an interview with the Administrator, S1, who stated R1 was diabetic and (3) sugar-free meals and an evening snack were provided to R1 daily. When R1 refused to eat, an Ensure was provided. S1 stated that the facility is supporting 8 Residents who have diabetes and special diets. The facility ensures their food is sugar-free. The department obtained and reviewed a Monthly Menu that revealed the facility is providing food to ensure Residents dietary needs are met.On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7) and 6 out of 6 Residents denied the allegation. An attempt to interview Resident #1 (R1) was made; however, R1 was not at the facility at the time of the visit and could not be reached by phone. On 10/16/2025 between 10:20 AM – 04:58 PM, the department interviewed Staff #1–#6 (S1–S6) and 6 out of 6 staff denied the allegation.On 10/17/2025 between 10:20 AM – 04:58 PM, the department requested, obtained, and reviewed the weekly menu plan from the facility, which showed that the resident in question was offered three meals a day plus two snacks daily. Interviews with residents revealed that they were served three meals and two snacks daily. The department obtained and observed the monthly dietary menu provided by the facility, which reflected that residents were provided with three meals a day plus snacks. Interviews with R2–R7 and S1–S6 revealed that food is served to the residents according to their dietary needs.


CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20250324094301
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: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 12/18/2025
NARRATIVE
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Based on records, observations, interviews conducted, and an analysis of evidence gathered, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated.

Allegation: Staff do not observe residents for changes in conditions

This complaint is alleging R1 may have required a higher level of care at a hospital or Skilled Nursing Facility. The department conducted an interview with the Administrator, Staff #1 (S1), who stated R1 had a Home Health LVN (W1), who worked 8:00 am -11:00 am seven days a week with R1. A1 stated the caregivers report all changes in conditions. Additionally, the facility has a wound specialist and a general physician to perform routine checks on all the residents. A1 stated Resident health issues are addressed immediately.
On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7) 6 out of 6 Residents express no concerns about staff monitoring changes in condition. An attempt to interview Resident #1 (R1) was made; however, R1 was not at the facility at the time of the visit and could not be contacted by phone. On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Staff (S#1-S#6) and 6 out of 6 staff denied the allegation. Staff interviewed stated that they monitor Residents and report any signs of change. Based on records, observations, interviews conducted, and an analysis of evidence gathered, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated.


CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20250324094301
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: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 12/18/2025
NARRATIVE
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Allegation: Staff did not assist residents with grooming.

This complaint is alleging that R1’s fingernails RP observed Daniel's fingernails to be three inches long. On 10/16/2025 between 10:20 AM – 04:58 PM, The department conducted and an interview with the Administrator, Staff #1 (S1), who stated the facility have staff who assist the residents with their grooming. The Administrator (S1) stated that every Friday the facility has a beauty shop open to assist the residents with hair and provide shaving services. Additionally, S1 stated R1 received assistance with grooming and R1’s nails were trimmed when they appeared to be overgrown by caregivers. This would occur in combination with R1’s shower.On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7) and 5 out of 6 Residents stated they are independent and do require assistance with grooming. 1 out of 6 Residents stated assistance was provided when showering. An attempt to interview Resident #1 (R1) was made; however, R1 was not present at the facility and could not be reached by phone. On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Staff #1–#6 (S1–S6) and 6 out of 6 Staff interviewed denied the allegation. S2 stated she assist Residents with their showers, nails, hair, and brushing teeth.Based on records, observations, interviews conducted, and an analysis of evidence gathered, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated.

Allegation: Staff do not maintain facility sanitary.

This complaint is alleging the facility has cobwebs, dirt and debris, and “greasy grimy” fingerprints on the doors walls as well as baseboards. The department conducted an interview with the Administrator, Staff #1 (S1), who stated the facility is cleaned daily by three housekeepers. A1 states two housekeepers clean the facility from 7:00 AM – 3:00 PM, and the third works from 10:00 AM – 5:00 PM daily.
On 10/16/2025, at 4:30 pm the department toured the facility and outside grounds. The department observed the facility to be clean and sanitary. During the facility tour, LPA Watson observed staff members mopping and gathering trash in bins.

CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20250324094301
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: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 12/18/2025
NARRATIVE
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On 10/16/2025 between 10:20 AM – 04:58 PM, the department conducted interviews with Residents #2–#7 (R2–R7) and 6 out of 6 Residents denied the allegation. The Residents interviewed stated there is approximately two staff members cleaning regularly on each floor. An attempt to interview Resident #1 (R1) was made, but R1 was not at the facility at the time of the visit.
Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with the Administrator Ella Naygas and a copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6