198320456-9-25-2025-11-AS-EMAZ-DQZQ2J-20260205104712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 09/25/2025
Date Signed: 09/25/2025 05:39:23 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, 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
09/15/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20250915160928

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: 106	DATE:	09/25/2025
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Michelle Brown		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff did not assist resident with transferring as needed
Facility staff did not assist resident with incontinence care as needed
Facility staff did not notify the fire authority within 48 hours of retaining a resident who is bedridden

INVESTIGATION FINDINGS:

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On 09/25/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Wellness Director, Michelle Brown, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During today’s visit, LPA interviewed Residents R2-R11, and received and reviewed Resident Assignment, and Outside Agency/Service Documentation.
During the initial visit conducted on 09/24/2025, LPA inspected the facility, interviewed Staff S1-S7, interviewed Resident R1, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Bedridden Resident List, notification letter to the local fire department informing them of a bedridden resident, Staff Training Logs, Resident R1 Physician’s Report, Resident R1 Physician's Orders, Needs and Service Plan, Assessment, and Admission Agreement.
The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

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-20250915160928

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: 09/25/2025

NARRATIVE

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Allegation: Facility Staff did not assist resident with transferring as needed
The allegation alleges there is not a sling for the Hoyer lift to transfer residents.

During record review, LPA received and reviewed a staff Training Log, dated 04/2025, on the topic of Hoyer Lift Training from PSL Hospice. Additionally, LPA received and reviewed a six (6) page handout on How to Use a Hoyer Lift that was provided to staff. LPA received and reviewed an invoice from Omni Care that a sling was ordered on 08/26/2025. During the facility tour, LPA observed a sling for the Hoyer lift, and lifts are operational. Additionally, LPA was shown slings that are available but was informed some residents do not like these slings and do not want them to be used when transferring them.

During interviews with Staff S1-S7, were asked if bedridden residents are assisted with transferring from their bed to chair, seven (7) out of seven (7) stated yes, bedridden residents are assisted with transferring from their bed to chair. Additionally, seven (7) out of seven (7) stated their bedridden resident refuses transferring from their bed to the chair. Staff S1-S7 were asked if there have been any issues with the Hoyer lift, seven (7) out of seven (7) stated no, there have been no issues with the Hoyer lift. Three (3) out of seven (7) stated when one of the residents was transferred to the hospital, the Hoyer sling did not return with them.
During interviews with Residents R1-R11, were asked if they are assisted with transferring when needed and wanted, two (2) out of eleven (11) stated no, they are not assisted with transferring when requested.

Allegation: Facility staff did not assist resident with incontinence care as needed

The allegation alleges that a residents incontinent needs are not being met.

During record review, LPA received and reviewed Assigned Resident list of residents who requires additional assistance that includes a bed bath, incontinent care, and grooming. On the Assigned Resident list there are reminders to check on residents every 2 hours and to care for incontinent needs when needed. LPA reviewed staff training conducted on Relias and observed Caring for Incontinent Residents was completed.

During interviews with Staff S1-S7 were asked how often incontinent residents are assisted with changing or checked to see if they need changing, seven (7) out of seven (7) stated they check residents every two (2) hours unless they require more frequent checks.
During interviews with Residents R1-R11, were asked if they are assisted with incontinence frequently, one (1) out of eleven (11) stated they are not assisted with incontinent care regularly. Additionally, Residents R1-R11 were asked if they have been left in a soiled diaper or briefs for an extended period of time, eight (8) out of eleven (11) stated they have not been left in soiled diapers for an extended period of time. Three (3) out of eleven (11) residents stated they do not receive assistance with incontinent care.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250915160928

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: 09/25/2025

NARRATIVE

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Allegation: Facility staff did not notify the fire authority within 48 hours of retaining a resident who is bedridden
The allegation alleges that the facility is not notifying the local fire department of a resident who is bedridden.

During an interview with Staff S1, was asked if notice is sent to the Culver City Fire Department informing them within 48 hours of retaining a resident who is bedridden according to the regulations, S1 stated yes a letter notifying them is sent within 48 hours. During record review, S1 provided LPA with a copy of two (2) letters that were faxed to the Culver City Fire Department dated 04/25/2025 and 09/01/2025 and the fax receipt. LPA observed the letters are updated lists of residents who are hospice, receive Oxygen, and who are bedridden, and their room number. Staff S1 informed LPA that when the list is updated whether removing a person or adding a person.

During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated.

During today's visit, LPA did not observe or cite any deficiencies.

An exit interview was conducted with Wellness Director, Michelle Brown, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

LIC9099 (FAS) - (06/04)

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