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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603319
Report Date: 07/23/2026
Date Signed: 07/23/2026 04:09:17 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
05/12/2026 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20260512084504
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: 56DATE:
07/23/2026
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Ella NaygasTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff are not properly trained to assist resident with CPAP
Staff are not able to effectively communicate with resident.
Facility failing to provide sufficient staffing
Resident requires a higher level of care
INVESTIGATION FINDINGS:
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On 07/23/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Ella Naygas, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During today’s visit, LPA interviewed Resident R1 and received Staff In-Service Training Logs.
During the initial visit on 05/12/2026, LPA inspected the facility, interviewed Staff S1-S6, interviewed Residents R2-R6, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Personnel Report (August 2025), Resident Roster (05/07/2026), Physician’s Reports (various dates), Appraisal/Needs & Service Plans (various dates), Inter-Facility Transfer Report (dated 12/19/2025), Office Progress Notes from Internal Medicine & Nephrology, UCLA (dated 01/21/2026), Kaiser Permanente After Visit Summary (dated 01/22/2026 – 01/26/2026), Cedars Sinai After Visit (dated 02/05/2026), West Hollywood Healthcare & Wellness Center Face Sheet (dated 03/26/2026) West Hollywood Healthcare & Wellness Center Transfer/Discharge Report (dated 04/10/2026),
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
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 4
Control Number 11-AS-20260512084504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 07/23/2026
NARRATIVE
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 West Hollywood Healthcare & Wellness Center Order Summary Report (dated 04/10/2026), West Hollywood Healthcare & Wellness Center Discharge Planning Review Form (dated 04/10/2026).
The investigation revealed the following:

Allegation: Staff are not properly trained to assist resident with CPAP


The allegation alleges that the resident is unable to operate the CPAP properly and staff on scene also do not know how the CPAP functions.
During a visit conducted on 07/23/2026, LPA observed staff assisting R1 in their room with their oxygen and other equipment.
During record review, LPA received and reviewed a Staff In-Service Training Log from April 2026, regarding how to properly assist with the CPAP machine. In the residents room, LPA observed the directions for the machine are next to it on the counter.
During interviews with Staff S1-S6, were asked if they have been trained on how to assist R1 with the CPAP machine, six (6) out of six (6) stated yes, they have received training on assisting R1 with the CPAP machine.
During interviews with R1-R6, were asked if they feel staff are properly trained, six (6) out of six (6) stated yes, the staff are properly trained. During an interview with Resident R1, was asked if staff assist them with their CPAP machine, R1 stated yes, they do. Additionally, R1 was asked if they believe staff are trained to assist with their CPAP machine, R1 stated yes, the staff were in the room receiving training when it was delivered and set up, they know how to use it.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff are not able to effectively communicate with resident.


The allegation alleges there is an English language barrier.
During interviews, LPA was able to effectively communicate with Caregivers and Management staff. LPA observed staff assisting and speaking with residents throughout the facility without an issue.
During interviews with Staff S1-S6, were asked if they have had any issues communicating with residents due to a language barrier, six (6) out of six (6) stated no, they have had no language barrier issues communicating with residents.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20260512084504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 07/23/2026
NARRATIVE
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During interviews with Residents R1-R6, were asked if they are able to effectively communicate with staff, six (6) out of six (6) stated they are able to effectively communicate with staff.
During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Facility failing to provide sufficient staffing


The allegation alleges that there is only one caregiver, a nurse, and manager working during the day.

During the facility visit, LPA observed three (3) caregivers, the Administrator, Administrator Assistant, maintenance, housekeeping, and kitchen staff working.


During record review, LPA received and reviewed the Personnel Report (LIC500). LPA observed that on the AM shift there are three (3) caregivers scheduled, on the PM shift there are two (2) caregivers scheduled, and on the NOC shift there are two (2) caregivers scheduled to work.
During interviews with Staff S1-S6, were asked if they feel there is enough staff on each shift to meet the needs of residents, six (6) out of six (6) stated yes, they feel there is enough staff on each shift. Additionally, four (4) out of six (6) staff stated there are only 25 residents who require assistance and 10 who require a total assist.
During interviews with Residents R1-R6, were asked if they feel there is enough staff to provide supervision and assistance to residents, six (6) out of six (6) stated yes, they believe there is enough staff on each shift.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Resident requires a higher level of care


The allegation alleges emergency personnel have expressed they believe a resident requires a higher level of care.
During record review, LPA received and reviewed the Physician’s Report for Residential Care Facilities for the Elderly (dated 11/03/2025) that indicates R1 does not require assistance with bathing, dressing, grooming, toileting, or transferring. R1 does require assistance with mediations, oxygen, and their CPAP machine. Additionally, LPA received and reviewed five (5) residents Physicians Report for Residential Care Facilities for
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20260512084504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 07/23/2026
NARRATIVE
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the Elderly (dated 12/17/2025 and 01/07/2026). LPA observed that a total of six (6) out of six (6) residents do not require assistance with bathing, dressing, grooming, toileting, or transferring. LPA received and reviewed Appraisal/Needs and Services Plan for six (6) residents. LPA observed six (6) out of six (6) residents Appraisal/Needs and Service Plans indicated residents are able to perform activities of daily living (ADL) and require assistance with medication management. LPA observed resident R1 requires assistance with equipment such as oxygen, CPAP, and nebulizer.
During interviews with Staff S1-S6, were asked if they feel any residents require a higher level of care, three (3) out of six (6) stated yes, they feel R1 requires a higher level of care because they take assist with putting on their mask and the resident takes it off.
During interviews with Residents R1-R6, were asked if they believe any of the residents at the facility require a higher level of care, six (6) out of six (6) indicated they do not believe any of the residents require a higher level of care. Additionally, LPA asked R1 if they believe they require a higher level of care, R1 stated no, they do not believe they require a higher level of care.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Caregiver, Yesenia Robles, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4