198320456-5-28-2025-11-AS-SCIS-DK523K-20250731170228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 05/28/2025
Date Signed: 05/28/2025 03:59:06 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/26/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20241126115531

FACILITY NAME:	TERRAZA COURT SENIOR LIVING		FACILITY NUMBER:	198320456
ADMINISTRATOR:	KAVANAUGH, BRITTANY		FACILITY TYPE:	740
ADDRESS:	10955 WASHINGTON BLVD		TELEPHONE:	(310) 838-7800
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	170	CENSUS: 99	DATE:	05/28/2025
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Michelle Brown, Wellness Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide adequate care and supervision to a resident

INVESTIGATION FINDINGS:

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*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 1/15/25.

On 1/15/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted a subsequent unannounced visit to this facility. LPA was met by Executive Director, Brittany Kavanaugh and explained the purpose of the visit is to investigate and deliver findings for the allegation mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 12/2/24, LPA Shirley spoke to facility Executive Director, Brittany Kavanaugh and reviewed facility records. LPA requested and received copies of staff and resident rosters, shower schedule, and special incident reports involving Resident 1 (R1), Admissions Agreement, Emergency Contacts, Physician’s report, 10/30/24, preplacement appraisal12/2019, Appraisal/Needs and Services Plan, 5/17/24 Staff Schedule, Resident Assessment, and Assessment for Medication Self-Management.
Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

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-20241126115531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TERRAZA COURT SENIOR LIVING	FACILITY NUMBER: 198320456
	VISIT DATE: 05/28/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not provide adequate care and supervision to a resident

ON 12/2/24 LPA Felisa Shirley reviewed facility records. Per incident report dated 11/5/24, On 11/3/24 R-1 fell in the shower and was found the next morning by facility staff. LPA conducted a review of Appraisals/Needs and Services dated 5/17/24, which shows that R-1 was independent and did not require assistance with their activities of daily living such as bathing, grooming and able to feed herself. It was noted that staff should promote independency where tolerated. Per R-1’s Physician Report dated 10/30/24, R-1 was non-ambulatory, and was able to bathe, dress and groom themself. LPA Shirley observed that none of the records stated R1 was a fall risk. Per facilities Assisted Living Shower Sheet, R-1 is not listed as needing assistance with bathing.

On 1/15/25 LPA Shirley reviewed staff schedule for the dates of 11/3/24 and early hours of 11/4/24. Per the schedule, there were 5 staff scheduled between the hours of 2pm and 6:30am.

ON 12/2/24 LPA Shirely interviewed Facility Administrator Brittany Kavanaugh. Per interview with Administrator, R-1 was not a fall risk and walked with the assistance of a walker. No unsteadiness was noted in her gait.

On 12/2/24, LPA Shirley interviewed staff 1 thru staff 10(S-1 thru S-10), of those interviewed, 9 out of 10 denied the allegation with 1 staff answering with something other than confirming or denying the allegation. On 12/2/24, LPA Shirley interviewed residents 2 thru resident 7 (R-2 thru R-7), of those interviewed, 6 out of 6 answered denied the allegation. LPA was attempted to interview R-1 but was unable as they were hospitalized.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20241126115531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: TERRAZA COURT SENIOR LIVING	FACILITY NUMBER: 198320456
	VISIT DATE: 05/28/2025

NARRATIVE

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Based on interviews, available evidence, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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.

There were no deficiencies cited.

A copy of this report was provided to the Executive Director Brittany Kavanaugh. There were no deficiencies cited. An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

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