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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602257
Report Date: 09/13/2022
Date Signed: 09/13/2022 11:52:37 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/12/2021 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20210312090412
FACILITY NAME:MARBLE TERRACE IIFACILITY NUMBER:
197602257
ADMINISTRATOR:GODLEWSKA, ELIZABETHFACILITY TYPE:
740
ADDRESS:19030 MIRANDA AVENUETELEPHONE:
(818) 345-8971
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 5DATE:
09/13/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Bozena KozbialTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handles resident in a rough manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Bozena Kozbial to deliver the final finding of the allegations mentioned above:
It was alleged that staff handles resident in a rough manner. On 03/19/2021, from 10am to 330pm, LPA obtained and reviewed resident records, and conducted interviews. On 05/25/2021, from 6pm to 730pm, LPA conducted additional interviews with facility staff. During today’s visit, from 945am to 12pm, LPA conducted interviews with residents, staff, and other witnesses, pertaining to the complaint. From information obtained, it was revealed to LPA, that resident # 1 (R1) has several physical ailments that require staff to assist with dressing and bathing, and other daily functions. It was also reported, that R1 often experiences confusion and R1’s perception of reality could be deemed not accurate and false. LPA was not able to interview R1, due to R1, being hospitalized, and facility staff was unsure when R1 would return. Although it was alleged staff handles resident in a rough manner, LPA was able to determine through interviews and documentation, there is insufficient evidence to prove the allegation. Also, from today’s visit, it was revealed from residents, staff are gentle and handle residents with care. Therefore, the allegation is UNSUBSTANTIATED at this time.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
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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