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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426281
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:43:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:TERRACE GARDENSFACILITY NUMBER:
366426281
ADMINISTRATOR:MAWIKERE, DEKKIFACILITY TYPE:
740
ADDRESS:22626 FLAMINGO ST.TELEPHONE:
(909) 824-8126
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:6CENSUS: 5DATE:
10/15/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Dekki Mawikeri - AdministratorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting a follow-up visit regarding complaint (#18-AS-20200608131822). LPA Colvin met with Administrator Dekki Mawikeri and advised them of the purpose of the visit. During LPA Colvin's visit, LPA Colvin addressed the following issue which was discovered during the investigation:

The complaint (#18-AS-20200608131822) that LPA Colvin investigated primarily revolved around an incident that occurred on 6/8/20 when paramedics were called due to a medical emergency regarding one of the residents at the facility. During LPA Colvin's review of Community Care Licensing's (CCL) record of reported incidents from this facility, LPA Colvin observed that CCL did not receive an Incident Report for 6/8/20. In fact, CCL has not received any Incident Reports or Death Reports from the facility since their opening in 2014. All unusual incidents (and deaths) which may pose a risk to a resident's health or safety (such as: calls to 911 or medical emergencies) are to be reported to CCL within 7 calendar days. Deficiency cited.

Additionally, facility staff admitted in interviews that the previous staff member (S1) took photos of the residents (R1) who was receiving emergency medical care from the paramedics. It was confirmed that the facility does not have prior written permission from the resident or responsible party to have photographs taken. Deficiency cited. R1 passed away and was unable to be interviewed regarding consent for photographs.

During today's visit, LPA Colvin observed that one of the staff members present (S2) was not associated to the facility. Additionally, the Administrator was unable to provide proof of background clearance for S2, as it was not in their file. According to previous interviews conducted by LPA Colvin, S2 has been working at the facility for 4 months. Deficiency cited. LPA Colvin will be assessing a civil penalty of $100 per day that S2 has worked at the facility without background clearance.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TERRACE GARDENS
FACILITY NUMBER: 366426281
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2021
Section Cited

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Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...the following:(1) A written report shall be submitted...within seven days...of any of the events specified ...(D) Any incident which threatens the welfare, safety or health of any resident... This was not met by:
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Based on record review, the Licensee did not comply with the above regulation with at least one incident. LPA Colvin observed that emergency services were called out to the facility on 6/8/20 but the facility never submitted an Incident Report to CCL. This was an immediate safety risk to all residents.
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date of 10/18/21.
Type A
10/18/2021
Section Cited

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Criminal Record Clearance: (e) All individuals ...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met by:
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Based on observations and record review, the Licensee did not comply with the above regulation with one staff member (S2). LPA Colvin observed that S2 was present in the facility wihtout proof of background clearance. S2 is not associated to the facility. This is an immediate safety risk to residents in care.
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all staff to have background clearance AND be associted to the facility prior to starting work/training at the facility. Requested items to be submitted to LPA Colvin by the Plan of Correction date of 10/18/21.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TERRACE GARDENS
FACILITY NUMBER: 366426281
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities : (a) In addition to the rights listed...residents... ave all of the following personal rights:
(1) To have...privacy in...medical treatment, personal care and assistance... This requirement was not met as evidenced by:
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Based on interviews, the Licensee did not comply with the above regulation with at least one resident (R1). Licensee stated that S1 took photos of R1 when paramedics responded to provide medical aid. Licensee does not have consent on file. This posed a potential personal rights violation to R1.
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Type B
10/29/2021
Section Cited

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Personnel Records : (a) The licensee shall ensure...records are maintained on...each employee. Each personnel record shall contain...: (13) For employees...(B) Documentation of either a criminal record clearance or a criminal record exemption... This requirement was not met by:
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Based on record review and interview, the Licensee did not comply with the above regulation with one staff member (S2). Licensee was unable to provide LPA Colvin with proof of clearance or transfer in S2's personnel file. This is a potential safety risk to all 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: TERRACE GARDENS
FACILITY NUMBER: 366426281
VISIT DATE: 10/15/2021
NARRATIVE
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Since it was reported to LPA Colvin that S2 has worked for 4 months and the facility does not have any records stating otherwise, LPA Colvin will issue penalties for the maximum of 5 days. $100 per day x 5 days = $500 in civil penalties being assessed today.

Lastly, all staff files must contain pertinent records that reflect their eligibility to be employed at the facility. LPA Colvin was unable to confirm S2's background clearance due to the facility not having a copy of it in their file. Deficiency cited.

LPA Colvin conducted an exit interview with Administrator Dekki Mawikeri, and a copy of this report, LIC809D, LIC421BG, and appeal rights were provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4