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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 09/08/2026
Date Signed: 09/09/2026 02:01:44 PM

Substantiated


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
06/23/2026 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260623091011
FACILITY NAME:TERRAZA COURT SENIOR LIVINGFACILITY NUMBER:
198320456
ADMINISTRATOR:LINDA POYTHRESSFACILITY TYPE:
740
ADDRESS:10955 WASHINGTON BLVDTELEPHONE:
(310) 838-7800
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:170CENSUS: 94DATE:
09/08/2026
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:
Linda Poythress (Administrator)		TIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff will not respond to resident’s call button in a timely manner.
INVESTIGATION FINDINGS:
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On 09/08/2026 at 08:35am, the Department conducted an subsequent complaint visit at the facility listed above to reveal the investigation findings. The Department met with Linda Poythress (Administrator) and explained the purpose of the visit.

The investigation consisted of the following: On 06/30/2026, the Department conducted interviews with 9 Staff (S1 - S9),10 Residents (R1 - R10) between the hours of 9:07am - 2:36pm and on 07/09/2026 at 12:22pm with Administrator (A1). The Department requested and obtained the following documentation such as Staff Roster (dated 05/19/2026), Resident Roster (received 06/30/2026), Plan of Operations, Resident 1's documentation such as LIC 602A Medical Assessment for Residential Care Facilities for the Elderly(dated August 2025), R1's Assessment for Admission to Assisted Living (dated 02/25/2026) R1's RCFE Service Plan (dated 04/17/2026), R1's Notes (April - June 2026) Residence & Care Agreement Transportation & Appointment Coordination Policy, Personal Conduct at the Workplace Policy, Conflict Resolution in the Workplace Policy, Call Light Response Policy (10 Minutes Standard), continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
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 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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Basic Care/Dressing/Bathing/Resident Toileting Policy (dated 12/05/2017) In Service Training (dated 04/24/2026, 05/15/2026, 05/20/2026), Weekly Menus (dated 04/26/2026) and Radio/Walkie Talkie Signature Sheet (dated 04/02/2026).

The investigation revealed the following:
Allegation: Staff will not respond to resident’s call button in a timely manner.
It was alleged that staff did not respond to the resident’s call button within a reasonable timeframe.

Administrator interview: On 07/09/2026 at 12:22pm, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated the facility’s call light response policy requires a 5-minute response time. A1 stated staff respond via intercom during front desk hours and that delays are addressed through corrective action.

Staff interviews: On 06/30/2026 between the hours of 9:07am - 2:36pm, the Department interviewed 9 staff regarding the allegation. 4 out of 9 staff denied the allegation and stated they respond promptly when notified over the walkie talkie. 5 out of 9 staff did not confirm nor deny the allegation and stated residents frequently complain when staff do not respond immediately. Staff stated delays may occur due to workload or miscommunication from the front desk.

Resident interviews: On 06/30/2026 between the hours of 10:05am - 2:11pm, the Department interviewed 10 residents regarding the allegation. 1 out of 10 resident confirmed the allegation and stated he waited an hour for assistance and experienced no response at night. 6 out of 10 residents denied the allegation and stated they have not experienced or observed call light delays. 3 out of 10 residents did not confirm nor deny the allegation and stated they experienced past delays or observed delays for other residents.

Record review: On 08/28/2026 between 10:00am - 11:30am, the Department conducted a records review. The Call Light Response Policy requires staff to acknowledge and address call lights within 10 minutes and document delays exceeding 10 minutes of activation and to notify another available team member if they are unable to respond within that timeframe. The policy requires documentation of delays exceeding 10 minutes and directs staff to assess the resident’s needs upon entering the room, prioritize safety concerns, and escalate unresolved requests to supervisory staff.

Investigation findings continue on LIC 9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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 The policy also assigns responsibility to unit leadership to review call-light response patterns and address non-compliance. These requirements demonstrate that the facility has written procedures directing staff to respond promptly to call lights and to ensure timely follow through. In service logs dated 04/15/2026 confirm staff training on call light response. The Residence and Care Agreement states the emergency call system is monitored 24 hours per day.

Observation:
On 09/08/2026 between the hours of 11:53am - 12:29pm, the Department conducted an observation related to call-light response in Room 104. At 11:53am, the Department activated the call light in Room 104. The resident spoke with someone over the call-light intercom and requested Tylenol. At 11:53am, a caregiver walked past Room 104. At 11:55am, a caregiver exited Room 111 to empty the trash. At 11:59am, the Department notified a staff member that the resident in Room 104 was requesting Tylenol. At 12:00pm, the resident in Room 113 yelled for help, and a caregiver entered the room and informed the resident that assistance was coming. At 12:02pm, two caregivers entered Room 105 and asked the resident if they wanted something to eat. At 12:04pm, a caregiver entered the elevator.At 12:05pm, the Department returned to Room 104 and asked the resident whether staff had entered the room or provided an explanation. The resident stated that no staff had entered the room. At 12:05pm, the call light in Room 104 was activated a second time. At 12:06pm, the Department was informed that a medtech had been notified. At 12:19pm, the Department activated the call light in Room 104 for a third time. The Department remained in the Room 104 until 12:29pm and observed that no staff entered Room 104 and no update or explanation was provided to the resident.

Substantiated: Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview with Linda Poythress (Administrator) and a copy of this report was provided with appeal rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 15
Control Number 11-AS-20260623091011
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met by: Based on observation &
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The facility will conduct an in service staff training in regards activating the call lights in the residents room & tracking the staff response time to ensure staff respond to call lights within the required timeframe per the facility policy.
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interviews, the facility did not ensure prompt response to a resident’s call light. On 09/08/2026, the Dept activated the call light (3) times in Rm 104 between 11:53am - 12:29pm, & no staff entered the room or provided an update. This violation poses a potential health, safety, and personal rights risk to residents in care.
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The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 15
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
06/23/2026 and conducted by Evaluator Zina Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260623091011

FACILITY NAME:TERRAZA COURT SENIOR LIVINGFACILITY NUMBER:
198320456
ADMINISTRATOR:LINDA POYTHRESSFACILITY TYPE:
740
ADDRESS:10955 WASHINGTON BLVDTELEPHONE:
(310) 838-7800
CITY:CULVER CITYSTATE:CAZIP CODE:
90232
CAPACITY:170CENSUS: 94DATE:
09/08/2026
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:
Linda Poythress (Administrator)		TIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff leaves resident soiled for extended periods of time.
Staff does not have adequate staffing to meet resident’s care needs.
Staff will engage in a verbal altercation regarding the resident in the presence of the resident.
Staff does not ensure resident is provided transportation for medical appointments.
Staff does not provide residents with quality food meals.
Staff did not follow resident’s admissions agreement.
INVESTIGATION FINDINGS:
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On 09/08/2026 at 08:35am, the Department conducted an subsequent complaint visit at the facility listed above to reveal the investigation findings. The Department met with Linda Poythress (Administrator) and explained the purpose of the visit.

The investigation consisted of the following: On 06/30/2026, the Department conducted interviews with 9 Staff (S1 - S9) 10 Residents (R1 - R10) between the hours of 9:07am - 2:36pm and on 07/09/2026 at 12:22pm with Administrator (A1). The Department requested and obtained the following documentation such as Staff Roster (dated 05/19/2026), Resident Roster (received 06/30/2026), Plan of Operations, Resident 1's documentation such as LIC 602A Medical Assessment for Residential Care Facilities for the Elderly(dated August 2025), R1's Assessment for Admission to Assisted Living (dated 02/25/2026) R1's RCFE Service Plan (dated 04/17/2026), R1's Notes (April - June 2026) Residence & Care Agreement Transportation & Appointment Coordination Policy, Personal Conduct at the Workplace Policy, Conflict Resolution in the Workplace Policy, Call Light Response Policy (10 Minutes Standard), continues on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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Basic Care/Dressing/Bathing/Resident Toileting Policy (dated 12/05/2017) In Service Training (dated 04/24/2026, 05/15/2026, 05/20/2026), Weekly Menus (dated 04/26/2026) and Radio/Walkie Talkie Signature Sheet (dated 04/02/2026).

The investigation revealed the following:
Allegation: Staff leaves resident soiled for extended periods of time.
It was alleged that the resident remained in soiled conditions for prolonged periods due to delayed care.

Administrator interview: On 07/09/2026 at 12:22pm, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated the facility performs incontinence checks every 2 hours. A1 stated that staff conduct more frequent checks for residents who soil heavily. A1 stated that any delays in incontinence care are addressed through corrective action and staff in-service training.

Staff interviews: On 06/30/2026 between the hours of 9:07am - 2:36pm, the Department interviewed 9 staff regarding the allegation. 6 out of 9 staff denied the allegation and stated they respond promptly to incontinence needs and have not observed residents remaining soiled for extended periods. 3 out of 9 staff did not confirm nor deny the allegation and stated they have experienced occasional delays when they were assisting another resident and could not respond immediately.

Resident interviews: On 06/30/2026 between the hours of 10:05am - 2:11pm, the Department interviewed 10 residents regarding the allegation. 1 out of 10 resident confirmed the allegation and stated he waited about an hour for incontinence care, remained soiled once, and experienced staff failing to return several times. 7 out of 10 residents denied the allegation and stated they have not experienced or observed delays in incontinence care. 2 out of 10 residents did not confirm nor deny the allegation. R6 stated they experienced delays upon admission but has not experienced delays recently. R9 stated they are independent but has observed other residents waiting and has looked for staff to assist them.

Record review: On 08/28/2026 between 10:00am - 11:30am, the Department conducted a records review and observed the following: The facility does not have incontinent logs The Admission Assessment identifies the resident as having paraplegia and neuromuscular dysfunction of the bladder requiring a suprapubic catheter.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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 The assessment documents that the resident requires a 2 person assist for toileting and incontinence care. The RCFE Service Plan confirms that incontinence care is required daily and as needed. Facility Policy Care 01 requires incontinent care to be provided as necessary, including nighttime hours. Procedure #9(e) requires incontinent care as part of bedtime care. Facility Policy MC-PC 04 requires staff to initiate toileting at least every 2 hours and to change incontinent products as needed.

On 09/08/2026 between the hours of 10:30am - 10:45am the Department reviewed the facility’s Care #1 – Basic Care policy. The policy requires individualized care plans based on admission and re-appraisals and directs staff to monitor residents routinely throughout each shift. The policy states that residents requiring assistance must receive full intervention, including toileting, removal of soiled clothing, and bedtime care that includes toileting and safety checks. The policy further requires staff to familiarize themselves with resident status at the beginning of each shift and to document and report any unusual information or changes in condition. These requirements demonstrate that the facility has written procedures directing staff to provide timely toileting assistance and to prevent residents from remaining in soiled conditions.

Based on information gathered through interviews and record reviews, there is not enough 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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Allegation: Staff does not have adequate staffing to meet resident’s care needs.
It was alleged that staffing levels were insufficient to meet the resident’s care needs, including required assistance.

Administrator interview: On 07/09/2026 at 12:22pm, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated staffing schedules are maintained. A1 stated that staffing shortages are addressed by calling in additional staff or having management provide coverage. A1 stated that two-person assist residents receive care through staff pairing.

Staff interviews: On 06/30/2026 between the hours of 9:07am - 2:36pm, the Department interviewed 9 staff regarding the allegation. 7 out of 9 staff denied the allegation and stated staffing levels have not affected their ability to provide care for two-person assist residents. 2 out of 9 staff did not confirm nor deny the allegation and stated staffing levels vary when the facility is short staffed, which may result in delays.

Resident interviews: On 06/30/2026 between the hours of 10:05am - 2:11pm, the Department interviewed 10 residents regarding the allegation. 3 out of 10 residents confirmed the allegation and stated they experienced inconsistent staff availability, staff stating the facility was short staffed, and staff leaving mid task. 5 out of 10 residents denied the allegation and stated they have not experienced or observed staffing shortages. 2 out of 10 residents did not confirm nor deny the allegation and stated they experienced occasional delays but no direct impact on care.

Record review: On 08/28/2026 between 10:00am - 11:30am, the Department conducted a records review. The Admission Assessment and Service Plan identify the resident as requiring a 2 person total assist for transfers and ambulation using a Hoyer lift. The RCFE Service Plan dated 04/17/2026 specifies “2 person Hoyer lift assist” for mobility and transfer assistance. An in service training record dated 04/24/2026 documents Hoyer lift training conducted by PSL Hospice. The Staffing Roster lists active caregivers and shift schedules. The Residence and Care Agreement states resident appraisals are used to determine and monitor staffing levels.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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On 09/08/2026 between the hours of 9:00am - 10:45am, the Department reviewed the he facility’s Care #1 – Basic Care policy. The policy requires staff to monitor residents routinely, assist with ambulation and transportation as needed, and complete morning and bedtime care tasks. The policy also requires staff to communicate resident status changes to the Assisted Living Director and to document all pertinent information for the following shift. These procedures indicate that the facility has established expectations for staff coverage and continuity of care across shifts. The Department also reviewed the Conflict Resolution in the Workplace Policy, which requires staff to address disagreements professionally and to report unresolved conflicts to supervisors or management. This policy supports maintaining effective teamwork and communication, which are necessary for meeting resident care needs. Also the LIC 500 Facility Personnel Report dated 05/19/2026. The report documented 38 caregivers assigned across all shifts, including 18 caregivers scheduled for the morning shift from 6:00am to 2:00pm, 14 caregivers scheduled for the evening shift from 2:00pm to 10:00pm, and 6 caregivers scheduled for the NOC shift from 10:00pm to 6:00am. The report also listed 3 medtechs who assist with caregiving, with 2 medtechs assigned to the evening shift and 1 medtech assigned to the NOC shift. The Department additionally reviewed the updated LIC 500 (dated 09/01/2026), which reflected staffing modifications. The updated report documented 4 caregivers/medtechs, with 3 assigned to the evening shift and 1 assigned to the NOC shift. It also listed 7 medtechs, with 3 assigned to the morning shift, 1 assigned to the evening shift, 1 assigned to the NOC shift, and 2 medtechs whose shift times were not listed. The updated report further documented 24 caregivers, with 12 assigned to the morning shift, 8 assigned to the evening shift, and 4 assigned to the NOC shift. These staffing records demonstrate that the facility maintains caregiver and medtech coverage across all shifts and updates staffing assignments as needed.

Based on information gathered through interviews and record reviews, there is not enough 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 9 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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Allegation: Staff will engage in a verbal altercation regarding the resident in the presence of the resident.
It was alleged that staff engaged in verbal disputes in the presence of the resident during care tasks.

Administrator interview: On 07/09/2026 at 12:22pm, the Department interviewed A1 regarding the allegation. A1 stated staff are required to remain cordial and professional. A1 stated disagreements must be handled away from residents and that incidents result in investigation and corrective action.

Staff interviews: On 06/30/2026 between the hours of 9:07am - 2:36pm, the Department interviewed 9 staff regarding the allegation. 1 out of 9 staff confirmed the allegation and stated she witnessed staff arguing during care tasks. She stated the disagreements were not frequent and the staff involved were terminated. 8 out of 9 staff denied the allegation and stated they have not witnessed or participated in verbal altercations in the presence of residents.

Resident interviews: On 06/30/2026 between the hours of 10:05am - 2:11pm, the Department interviewed 10 residents regarding the allegation. 1 out of 10 resident confirmed the allegation and stated he witnessed staff arguing, using inappropriate language, and making disrespectful gestures. 7 out of 10 residents denied witnessing staff arguing. 2 out of 10 residents did not confirm nor deny the allegation and stated they heard about incidents or observed minor disagreements.

Record review: On 08/28/2026 between 10:00am - 11:30am, the Department conducted a records review. The Personal Conduct Policy requires staff to maintain professionalism and appropriate communication. The Conflict Resolution Policy requires disagreements to be addressed privately and prohibits disrespect or aggression. Care guidelines require maintaining dignity and a peaceful environment.

On 09/08/2026 between the hours of 10:30am - 10:45am, the Department reviewed the facility’s Conflict Resolution in the Workplace Policy. The policy requires staff to maintain respect, confidentiality, fairness, and professionalism when addressing workplace disagreements. The policy directs employees to attempt informal resolution through direct communication and to report unresolved conflicts to supervisors or human resources. The policy requires investigations, mediation, and recommended corrective actions when formal resolution is needed. The policy also requires documentation of conflicts and follow up actions. These procedures demonstrate that the facility has written expectations prohibiting disruptive behavior and requiring staff to resolve disagreements away from residents.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 10 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
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Based on information gathered through interviews and record reviews, there is not enough 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.

Allegation: Staff does not ensure resident is provided transportation for medical appointments.
It was alleged that the resident missed medical appointments due to unavailable or unreliable transportation.

Administrator interview: On 07/09/2026 at 12:22pm, the Department interviewed A1 regarding the allegation. A1 stated the van is operational. A1 stated transportation is scheduled 48 hours in advance and wheelchair-accessible transportation is arranged when needed.

Staff interviews: On 06/30/2026 between the hours of 9:07am - 2:36pm, the Department interviewed 9 staff regarding the allegation. 5 out of 9 staff denied the allegation and stated residents have not missed appointments and the facility vehicle is operational. Staff stated alternative transportation is available through the Business Office, resident family, or primary care physician, including Lyft, Uber, and Access. 4 out of 9 staff did not confirm nor deny the allegation and stated the facility does not have a wheelchair-accessible van or that residents may have missed appointments.

Resident interviews: On 06/30/2026 between the hours of 10:05am - 2:11pm, the Department interviewed 10 residents regarding the allegation. 2 out of 10 residents confirmed transportation issues including missed appointments, long-term van inoperability, and reliance on alternative transportation. 6 out of 10 residents denied the allegation and stated they have not experienced transportation delays. 2 out of 10 residents did not confirm nor deny the allegation and stated they had limited knowledge or isolated experiences.

Record review: On 08/28/2026 between 10:00am - 11:30am, the Department conducted a records review. The Transportation Policy requires timely coordination of medical transportation and documentation of missed appointments. The LIC 500 lists a designated driver. The RCFE Service Plan notes non-emergency transportation availability. The Residence and Care Agreement states scheduled transportation is provided within a 10-mile radius.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 11 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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On 09/08/2026 between the hours of 9:00am -10:00am, the Department conducted an additional records review of the facility’s Plan of Operation and transportation policies. The Plan of Operation assigns the Administrator responsibility for ensuring medical appointments are scheduled and for assisting residents with arranging all transportation needs. Under basic rate services, the facility is required to make or assist in making transportation arrangements for medical and dental appointments, and for residents receiving SSI/SSP, transportation to required medical and dental appointments is included as a basic service provided at facility expense. The Department also reviewed the facility’s Transportation & Appointment Coordination Policy, which requires the assisted living community to provide or coordinate transportation in a safe, timely, and documented manner. Wellness or administrative staff must schedule appointments, record appointment details, confirm transportation and mobility needs, and enter appointments into the community calendar. Transportation requests must be submitted 48–72 hours in advance for non urgent visits, and staff must confirm appointments and transportation 24 hours prior. Drivers must receive a route sheet that includes mobility needs, destination, appointment time, and emergency contacts, and must assist residents safely to and from the vehicle. If an appointment is missed or rescheduled, staff must notify the provider, reschedule promptly, update the resident or family, and document the reason for the missed appointment in the resident’s record. Management is responsible for overseeing the transportation program, ensuring adequate staffing and vehicle maintenance, and conducting monthly audits of appointment logs to monitor compliance and timeliness.

Based on information gathered through interviews and record reviews, there is not enough 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 12 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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Allegation: Staff does not provide residents with quality food meals.
It was alleged that the meals provided were of poor quality and lacked adequate options.

Administrator interview: On 07/09/2026 at 12:22pm, the Department interviewed A1 regarding the allegation. A1 stated meals follow a dietitian approved menu. A1 stated complaints are investigated and menu changes are implemented when needed.

Staff interviews: On 06/30/2026 between the hours of 9:07am - 2:36pm, the Department interviewed 9 staff regarding the allegation. 2 out of 9 staff confirmed the allegation and stated food quality has changed and residents have complained. 3 out of 9 staff denied the allegation and stated food quality is good, has not changed, and menu options are sufficient. 4 out of 9 staff did not confirm nor deny the allegation and stated food availability is inconsistent and food may run out if second servings are given before first servings.

Resident interviews: On 06/30/2026 between 10:05am - 2:11pm, the Department interviewed 10 residents regarding the allegation. 3 out of 10 residents confirmed concerns regarding food quality, limited options, and complaints from other residents. 4 out of 10 residents denied the allegation and stated food quality is acceptable. 3 out of 10 residents did not confirm nor deny the allegation and stated they experienced isolated issues or variable food quality.

Record review: On 08/28/2026 between 10:00am - 11:30am, the Department conducted a records review. The LIC 500 lists a Dietary Director. The Residence and Care Agreement states the facility will serve 3 nutritionally balanced meals and snacks daily. Facility Policy Care 01 requires staff to assist residents to meals.

On 09/08/2026 between the hours of 10:00am - 10:25am, the Department conducted an additional records review of the facility’s weekly menus (dated 04/26/2026 - 08/01/2026). The menus reviewed included multiple weeks of planned meals for breakfast, lunch, and dinner, each listing a variety of entrées, vegetables, fruits, soups, salads, and desserts. The menus reflected nutritionally balanced offerings such as eggs, wholegrain toast, fresh fruit, soups, salads, lean proteins, vegetables, and baked rolls. The menus also included themed meals, seasonal items, and alternative selections. Each weekly menu contained a notation that milk is offered at every meal.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 13 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
NARRATIVE
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 The menus were signed by a dietitian, indicating professional review and approval of the planned meals. The Department also reviewed the facility’s pull and prep sheets, which documented the ingredients and preparation steps required for each meal, including fresh produce, proteins, and side dishes. These documents demonstrate that the facility maintains a structured meal planning system, uses dietitian-approved menus, and provides a variety of food options intended to meet nutritional standards.

Observation: On 09/08/2026 between the hours of 11:00am - 11:07am, the Department conducted an observation and observed the following: At 11:05 the Department entered the kitchen and observed lunch being prepared which included pastrami sandwiches, salad, roasted potatoes. For the resident who get room service oranges, cranberry or lemonade juice and yogurt were on the trays. In the pantry there is bread, pasta, chips. In the refrigerator there is chicken soup, egg salad, sausage, vegetables such as carrots, tomatoes, broccoli, squash, avocados, kale sliced ham, cheese, bell peppers, strawberries, in the freezer chicken, green beans, ice cream uncrustable peanut butter and jelly sandwiches and chicken pot pie

Based on information gathered through interviews and record reviews, there is not enough 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 14 of 15
Control Number 11-AS-20260623091011
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: 09/08/2026
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Allegation: Staff did not follow resident’s admissions agreement.
It was alleged that the resident’s room assignment did not align with the terms of the admissions agreement.

Administrator interview: On 07/09/2026 at 12:22pm, the Department interviewed A1 regarding the allegation. A1 stated room assignments follow admissions agreements. A1 stated room changes are communicated in person and disputes are addressed with residents and their representatives.

Staff interviews: On 06/30/2026 between the hours of 9:07am - 2:36pm, the Department interviewed 9 staff regarding the allegation. 2 out of 9 staff denied the allegation and stated room assignments are documented and communicated by the Administrator or Wellness Director. 7 out of 9 staff did not confirm nor deny the allegation and stated residents have expressed concerns about room changes, sometimes due to not wanting to share a room with a roommate.

Resident interviews: On 06/30/2026 between 10:05am - 2:11pm, the Department interviewed 10 residents regarding the allegation. 4 out of 10 residents confirmed issues with room assignment including unmet expectations for private rooms, room changes, and concerns about room conditions. 4 out of 10 residents denied the allegation and stated they have not experienced room assignment issues. 2 out of 10 residents did not confirm nor deny the allegation and stated they had limited knowledge or no concerns.

Record review: On 08/28/2026 between 10:00am - 11:30am, the Department conducted a records review. The Residence and Care Agreement states the resident selected Apartment #105 and may reside there month-to-month. Section VII (B) requires 30 days’ written notice before substituting the apartment unless the resident agrees, a vacant bed must be filled, or an emergency requires relocation. The Resident Roster documents the resident assigned to Room 105A with Room 105B vacant.

Based on information gathered through interviews and record reviews, there is not enough 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.

Exit interview conducted with Linda Poythress (Administrator) and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2026
LIC9099 (FAS) - (06/04)
Page: 15 of 15