198320456-6-30-2025-11-AS-JHAD-DJ7VUH-20250702164445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 06/26/2025
Date Signed: 06/30/2025 08:55:40 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
11/07/2024 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20241107165127

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: 74	DATE:	06/26/2025
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Denyanna Banda		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff did not prevent a resident from sustaining a fracture while in care.
Staff did not prevent resident from eloping from the facility.

INVESTIGATION FINDINGS:

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*** THIS REPORT SUPERSEDES REPORT DATED 04/17/2025 TO INCLUDE ADDITIONAL INFORMATION. THE FINDINGS REMAIN THE SAME. **
On April 17, 2025, Licensing Program Analyst (LPA) Pamela Bunker conducted a subsequent visit to gather information regarding the above allegations. LPA met with Memory Care Director, Denyanna Banda, and explained the purpose of the visit. LPA was granted entry to the facility.
The investigation consisted of the following: On April 17, 2025, the following documents were reviewed and/or obtained as part of the investigation: Personnel Report, Resident Roster, Special Incident Reports, Admission Agreement, Identification and Emergency Information, Physician’s Report, Medical Assessment, Medication Administration Records (MARs), Appraisal & Needs and Services Plan, Functional Capability Assessment, Preplacement Appraisal Information, Consent Forms, and UCLA Medical Center Records. Interviews were conducted with Staff Members #1–5 (S1–S5) and Residents #2–8 (R2–R8). Resident #1 (R1) was unavailable for an interview as they no longer reside at the facility. R1 passed away on December 21, 2024, after transferring to another care facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

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-20241107165127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA COURT SENIOR LIVING	FACILITY NUMBER: 198320456
	VISIT DATE: 06/26/2025

NARRATIVE

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Continued LIC9099-C page 2

The investigation revealed the following:

Allegation 1: Staff failed to prevent a resident from sustaining a fracture while in care.

It was alleged that on October 24, 2024, R1 exited the facility, began walking backward, and subsequently fell, sustaining a hip fracture. R1 was transported to the emergency room and diagnosed with the injury.

LPA interviewed Staff #1–5. 1 out of 5 staff members stated they were not present during the incident and could not provide details. 4 out of 5 staff members confirmed they were present and described that R1 was attempting to leave the memory care unit. R1 exited through a secured door and began walking backward, which led to the fall. Staff arranged transport to the hospital for medical evaluation.

LPA interviewed Residents #2-8 (R2–R8), and 7 out of 7 residents denied the allegation. LPA conducted a tour of the physical plant, but no surveillance cameras were observed. A review of R1’s file, including the Physician’s Report, Needs and Services Plan, and Preplacement Appraisal, did not indicate a documented history of falls. An incident report was submitted to Community Care Licensing (CCL) for the incident that occurred.

Based on the investigation, there is not enough evidence to support that staff failed to supervise R1, resulting in the resident sustaining a fracture.

Based on interviews, available evidence, observation, 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 deemed unsubstantiated.

See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20241107165127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA COURT SENIOR LIVING	FACILITY NUMBER: 198320456
	VISIT DATE: 06/26/2025

NARRATIVE

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Continued LIC9099-C page 3

Allegation 2: Staff failed to prevent a resident from eloping from the facility.

It was alleged that on October 24, 2024, R1 exited the facility without staff supervision. LPA interviewed Staff #1–5. 1 out of 5 staff members was not present during the incident but reported hearing that R1 never left the facility premises. 4 out of 5 staff members confirmed their presence during the incident and stated that while R1 exited the memory care unit, the resident did not leave the facility grounds and was under supervision at all times.

LPA interviewed residents #2-8 regarding the allegation, 7 out of 7 residents denied the allegation.

LPA conducted a tour of the physical plant and observed the facility's memory care unit is located on the second floor of the building. Based on LPA’s observation if a resident exits the memory care unit they would be in the hallway and would need to take an elevator down from the second floor to completely exit the facility premises.

Based on the investigation there is no evidence to support R1 eloped from the facility grounds.

A copy of the Complaint Investigation Report LIC9099, and LIC9099-C, was provided to the Memory Care Director Denyanna Banda.

An exit interview was conducted.
No deficiencies were cited.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 06/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025

LIC9099 (FAS) - (06/04)

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