198603472-3-14-2026-28-AS-LHIS-DS9PCU-20260317111228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603472
Report Date: 03/14/2026
Date Signed: 03/14/2026 12:14:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2026 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260302083503

FACILITY NAME:	TERN BAY HOME		FACILITY NUMBER:	198603472
ADMINISTRATOR:	BOATNER, VERRETTA		FACILITY TYPE:	735
ADDRESS:	2213 TERN BAY LANE		TELEPHONE:	(424) 338-3054
CITY:	LAKEWOOD	STATE: CA	ZIP CODE:	90712
CAPACITY:	3	CENSUS: 3	DATE:	03/14/2026
		UNANNOUNCED	TIME BEGAN:	11:33 AM
MET WITH:	Glenn Pratto, DSP		TIME COMPLETED:	12:19 PM

ALLEGATION(S):

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Facility did not administer medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to deliver findings for the above allegation. LPA met with Glen Pratto DSP and discussed the purpose of the visit. LPA got prior authorization for staff Glen Pratto to sign report by Program Supervisor Tracey Mitchell and read report to her over the phone.
On 03/09/2026 - Licensing Program Analyst (LPA) Alberto Lopez conducted an initial complaint investigation regarding the above allegation. LPA met with Dalia Delgado DSP and administrator Marsha Murray, arrived a short time later and assisted with the visit. LPA explained the reason for the visit.

The investigation consisted of the following: LPA interviewed six (6) S#1 – S#6 staff, one (1) client C#2, reviewed medications for C#1 -C#3, obtained pertinent medical documents for C#1. LPA asked facility for all discharge orders since C1 has been at home and hospitalized.
Between this visit and prior visit, LPA conducted several more interviews and obtained additional information.
(continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260302083503

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TERN BAY HOME	FACILITY NUMBER: 198603472
	VISIT DATE: 03/14/2026

NARRATIVE

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(continued from 9099)

The investigation revealed: allegation: Facility did not administer medication as prescribed. It is alleged that facility is not administering medication/liquids as prescribed and that is leading to client being frequently hospitalized. LPA interviewed a family member and a witness after initial visit. Client was admitted to facility on 11/14/2025. Since then, client has been hospitalized on 12/11/2025, 12/18/2025, 12/28/2025, 01/05/2026, 01/06/2026, 02/02/2026, 02/03/2026, 02/07/2026, 02/22/2026. Not once has any health professional at hospital raised concern or reported possible neglect on facilities part. LPA reviewed medications for all three clients residing at facility, and the medications are being administered as ordered. There was a self reported medication error on 02/02/2026 where Desmopressin was signed off as given and was still in the bubble pack. There is not enough evidence that the medication error caused client’s hospitalization. Before being admitted to Tern Bay, client was living with mother and during this time hospital records show that client was hospitalized on the following dates: 05/08/2025, 05/13/2025, 05/22/2025, 06/24/2025, 09/19/2025, 09/23/2025, 10/10/2025, and 10/29/2025. The client's hospitalization before and after client was admitted to facility show a consistent pattern and there is no evidence that facility was neglectful.

Based on documents reviewed and interviews, there is not enough evidence to substantiate the allegation that the facility did not administer medication/liquids as prescribed that led to multiple hospitalization of client. It appears more likely based on interviews, records of hospitalization months before admitted to facility and during client’s stay at facility that client may require a higher level of care.

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.

Exit interview was held and a copy of the report was provided

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2026

LIC9099 (FAS) - (06/04)

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