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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603319
Report Date: 11/08/2021
Date Signed: 11/08/2021 04:15:45 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/17/2021 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210917125609
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: 86DATE:
11/08/2021
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH: Ceclia Torres-SupervisorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 11/8/2021, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Torres, the facilities Supervisor and the purpose of the visit was explained.

The investigation consisted of the following: on 9/23/21, LPA Brown toured the physical plants. LPA observed on the 1st floor elevator southside of the building was not working. LPA interviewed Supervisor Clifford Johnson, he stated the elevator has been down since 8/18/21. LPA requested and obtained the following documents: Resident/Staff Roster, Incident report and elevator company contract/invoice completion.

The investigation revealed the following:

Regarding allegation: Facility is in disrepair.

LIC9099-C is on the next page.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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 3
Control Number 11-AS-20210917125609
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
VISIT DATE: 11/08/2021
NARRATIVE
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On 9/23/21, LPA conducted interview with supervisor Johnson. He stated the elevator has not been in operation since 8/18/21. He stated the original elevator company was no longer in services and had to locate a new company. He stated they have a contract with a new elevator company that will come out tomorrow to start work. LPA reviewed the contract which was a “Monthly Service Contract”. Contract did not indicate any invoice or notice on when elevator will be repaired. On 11/4/21, LPA interviewed Administrator Ella Nayqas and she stated the elevator has been down for 2 months. She stated the elevator company is waiting on a part and there is a problem with the shipping. She did not know when the elevator will be working but stated she has been contacting them every day.

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 Conducted, appeal rights were explained and a copy of this report was provided to Torres

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20210917125609
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BEVERLY HILLS TERRACE
FACILITY NUMBER: 198603319
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) 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, employees and visitors.

This requirement was not met as evidence by:
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Administrator will make sure elevator is in good condition and working at all times. Administrator will submit a plan on how they will ensure that the residents health and safety are met in the event if the elevator is down. Administrator will provide documenataion from the elevator company on when the elevator will be fixed to LPA by POC due date 11/9/2021
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Based on observation and interviews conducted, Licensee did not ensure elevator was accessible to residents in care. Administrator did not notify LPA that elevators was not in operations. This an immediate health and safety risk to clients in care.
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Type B
11/15/2021
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirement
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days..
This requirement was not met as evedience by:
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Supervisor provided to LPA incident report at the time of visi and did not notify CCLD. Administrator will review the regulation section and will send a statement that they read and understood the reporting requirements to LPA by POC date 11/15/21.
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Based on observation and interview conducted on 9/23/21, supervisor Johnson did not notify CCLD that the elevator not working.
This poses an immediate/Potential health & safety risk to 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3