198320456-9-9-2026-11-AS-UCOL-DYFVJ2-20261001162801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 09/08/2026
Date Signed: 09/09/2026 11:39:16 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, 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
08/14/2026 and conducted by Evaluator Zina Brown

COMPLAINT CONTROL NUMBER: 11-AS-20260814083639

FACILITY NAME:	TERRAZA COURT SENIOR LIVING		FACILITY NUMBER:	198320456
ADMINISTRATOR:	LINDA POYTHRESS		FACILITY TYPE:	740
ADDRESS:	10955 WASHINGTON BLVD		TELEPHONE:	(310) 838-7800
CITY:	CULVER CITY	STATE: CA	ZIP CODE:	90232
CAPACITY:	170	CENSUS: 97	DATE:	09/08/2026
		UNANNOUNCED	TIME BEGAN:	12:35 AM
MET WITH:	Linda Poythress (Administrator)		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff mismanage residents' medication.
Staff are threatening resident.
Staff are harassing resident.
Staff are not providing a safe environment for resident in care.
Staff did not safeguard residents belongings.

INVESTIGATION FINDINGS:

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On 09/08/2026 at 8:35am the Department conducted an unannounced subsequent complaint investigation at the facility listed above to deliver the investigation findings. The Department met with Linda Poythress (Administrator) and explained the purpose of the visit.

The investigation consisted of the following: On 08/17/2026 between the hours of 9:44am - 2:12pm, the Department conducted interviews with Administrator (A1), 7 Staff (S1 - S7) and 9 Resident (R1 - R9). The Department requested and obtained the following documentation such as Staff Roster (dated 08/14/2026), Resident Roster (updated 07/06/2026), R1's records such as LIC 602 (dated 07/09/2026), LIC 603 (dated 07/17/2026), Admission Agreement (dated 07/17/2026), Diet Order Communication Form (dated 07/17/2026), R1's Notes (dated 07/17/2026 - 08/12/2026) and Medication Administration Record (dated 07/17/2026 - 08/17/2026).

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: 1 of 7

Control Number 11-AS-20260814083639

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 investigation revealed the following:

Allegation: Staff mismanage residents' medication.
It was alleged that the resident reported being without their prescribed blood pressure medication for an extended period, despite being informed by their nurse practitioner that the medication had been ordered weeks earlier, and that staff were unable to provide clear information when they asked about the status of their medication.

Administrator Interview: On 08/17/2026 at 1:11pm, the Department interviewed A1 in regards to the allegation. A1 denied the allegation. A1 stated the facility conducts weekly medication room audits, reorders medications when supply reaches 10–7 days remaining, and receives cycle medications every two weeks. A1 further stated that R1’s blood pressure medication was included in the July 22, 2026 cycle delivery and that R1 receives a two-week supply regularly.

Staff Interviews: On 08/17/2026 between the hours of 9:31am - 2:15pm, the Department interviewed 7 staff in regards to the allegation. 1 out of 7 staff confirmed the allegation & indicated R1 going one day without their medication due to the pharmacy needed to refill prescription. 5 out of 7 staff denied the allegation by stating they did not observed R1 without medication and weren't aware of any refill issues. 1 out of 7 staff did not confirm nor deny the allegation and mentioned working on a different floor and doesn't know whether R1 experienced medication delays.

Resident Interviews: On 08/17/2026, between the hours of 9:46am - 1:39pm, the Department interviewed 9 residents in regards to the allegation. 3 out 9 residents confirmed the allegation with R1 stating their out of blood pressure medication for a couple weeks and was informed by their nurse practitioner medication was order on 07/27/2027. R8 stated having problem receiving their medication but did not go into further detail as to why. R9 mentioned that the facility was out of one of their medications. 6 out of 9 residents denied the allegation which stated having no problems receiving their medication nor R1 without their medication.

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 7

Control Number 11-AS-20260814083639

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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Records Review: On 09/04/2026 between the hours of 3:40pm–4:40pm, the Department conducted a records review and observed the following: The LIC 602A dated 07/09/2026 documents that Resident 1 (R1) is prescribed multiple medications and is noted as “alert & oriented x4” and “self responsible able to make needs known,” while also indicating that “all meds been keep and administer by Nursing,” confirming that the facility is responsible for medication administration . The administrator’s written statement included in the records indicates that R1’s blood pressure medication (Losartan 25mg) was added to the cycle delivery on 07/22/2026 and that the facility performs weekly medication room audits and reorders medications when supply reaches 10–7 days remaining . The MAR pages reflect medication administration entries for July–August 2026 with no gaps or omissions were visible in the pages provided. No documentation was found indicating that R1 was out of blood pressure medication for multiple weeks as reported by the RP, and no record of a medication-refill delay or pharmacy communication issue was included in the file.

On 09/08/2026 between the hours of 11:00am - 11:30am, the Department conducted Medication Administrator Record review and observed the following: 4 Medication Administrator Record (MAR) review was conducted and the Department did not observe any discrepancies with medication. For R1 (dated 08/28/2026) a letter from R1's primary care physician stated R1 is allowed access to their medication for self-administration with the exception of PRN controlled substance pain medications. Please check patient's blood pressure daily. Medication Release were signed and dated by R1 on 08/31/2026, 09/03/2026 and 09/07/2026 which stated medication entrusted to R1 include Carvedilol, Metformin 1000mg, Eliquis 25mg, Escitalopram 10mg, Jardiance 10mg, Losartan 25mg, Montelukast 10mg, Pravastatin Sodium 10mg, Cetirizine HCL 10mg, Mag-Oxide 400mg, Losartan 25mg, Diclofenac Sodium, Airsupra 90mcg/80mcg, Fluticasone 50mg, Levalbuterol 063mg, Trelegy Ellipta, Ondansetron 4mg, Naproxen 500mg, Albuterol HFA 90mcg and Carvedilol 125mg.

Unsubstantiated: 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: 3 of 7

Control Number 11-AS-20260814083639

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 are threatening resident.
It was alleged that the resident reported staff speaking to a resident in a manner that they perceived as verbally abusive and intimidating, causing the resident to feel threatened during interactions within the facility.

Administrator Interview: On 08/17/2026 at 1:11pm, the Department interviewed A1 in regards to the allegation. A1 denied the allegation. A1 stated that no concerns regarding threatening staff interactions with R1 had been reported by residents or employees. A1 explained that the facility takes inappropriate conduct seriously and follows corrective procedures, and stated no such reports involving R1 had occurred.

Staff Interviews: On 08/17/2026 between the hours of 9:31am - 2:15pm, the Department interviewed 7 staff in regards to the allegation. 7 out 7 staff denied the allegation by stating they had never heard staff speak to R1 in a threatening manner and had not observed threatening interactions.

Resident Interviews: On 08/17/2026, between the hours of 9:46am - 1:39pm, the Department interviewed 9 residents in regards to the allegation. 3 out of 9 residents confirmed the allegation with R1 stated staff made them feel threatened by the way things are presented. R4 stated staff told them certain resident were thrown out if they did not comply. R9 mentioned a medtech snatched the remote and had a street like demeanor. 6 out of 9 residents denied the allegation and stated they had not heard threatening statements toward themselves or other residents.

Records Review: On 09/04/2026 between the hours of 3:40pm–4:40pm, the Department conducted a records review and observed the following: A checklist referencing “facility communication logs” and “facility grievance/complaint records,” but no communication logs, grievance records, or incident reports documenting threatening interactions toward R1 were included nor mentioned.

Unsubstantiated: 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: 4 of 7

Control Number 11-AS-20260814083639

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 are harassing resident.
It was alleged that the resident reported staff engaging in conduct that a resident perceived as harassing, including speaking to her in a condescending or hostile tone and contributing to an environment that the resident described as emotionally distressing.

Administrator Interview: On 08/17/2026 at 1:11pm, the Department interviewed A1 in regards to the allegation. A1 denied the allegation. A1 stated that no concerns or documentation had been submitted regarding staff harassing R1. A1 explained the facility’s response process for such reports but confirmed that no harassment concerns involving R1 had been brought forward.

Staff Interviews: On 08/17/2026 between the hours of 9:31am - 2:15pm, the Department interviewed 7 staff in regards to the allegation out of 7 staff confirm the allegation and stated R1 appeared upset after an interaction with staff but did not know why. 6 out of 7 staff denied the allegation and indicated they had not observed harassing behavior toward R1.

Resident Interviews: On 08/17/2026, between the hours of 9:46am - 1:39pm, the Department interviewed 9 residents in regards to the allegation. 3 out of 9 residents confirmed the allegation with R1 indicating staff spoke to them in a condescending manner. R4 stated being told if you don’t like it, you can move out. R9 mentioned a staff turning down their TV so they couldn't hear. 6 out of 9 residents denied the allegation stated they had not heard or experienced harassment.

Records Review: On 09/04/2026 between the hours of 3:40pm–4:40pm, the Department conducted a records review and observed the following: No written complaints, internal investigation notes, or incident reports documenting harassing conduct were found. The records reviewed do not contain any documentation supporting the allegation that staff were verbally abusive, harassing, or contributing to a “hostile” environment.

Unsubstantiated: 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: 5 of 7

Control Number 11-AS-20260814083639

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 are not providing a safe environment for resident in care.
It was alleged that the resident reported feeling unsafe living in the facility, described the environment as hostile, and stated a resident attempted to seek assistance from local law enforcement due to concerns about their personal safety.

Administrator Interview: On 08/17/2026 at 1:11pm, the Department interviewed A1 in regards to the allegation. A1 denied the allegation. A1 stated that the facility had not received any reports from R1 indicating she felt unsafe. A1 also stated the facility was not aware of R1 attempting to seek help from law enforcement and confirmed that no law enforcement had contacted the facility.

Staff Interviews: On 08/17/2026 between the hours of 9:31am - 2:15pm, the Department interviewed 7 staff in regards to the allegation out of 7 staff confirmed the allegation with R1 expressed fear after an interaction with a maintenance staff member. 6 out of 7 staff denied the allegation and stated they had not observed R1 expressing fear or seen unsafe situations.

Resident Interviews: On 08/17/2026, between the hours of 9:46am - 1:39pm, the Department interviewed 9 residents in regards to the allegation. 5 out 9 residents confirmed the allegation stating they did not feel safe or observed unsafe interactions. 4 out 9 denied the allegation and they felt safe and had not observed unsafe conditions.

Records Review: On 09/04/2026 between the hours of 3:40pm–4:40pm, the Department conducted a records review and observed the following: The LIC 602A dated 07/09/26 documents R1 as ambulatory, able to follow directions, able to communicate needs, and able to leave the facility unsupervised, with all behavioral-risk indicators (disorientation, unsafe wandering, elopement, hallucinations, lack of hazard awareness) marked “No” . Staff schedules for August 2026 included in the PDF show continuous caregiver and med-tech coverage across AM, PM, and NOC shifts. No incident reports, safety-related grievances, or documentation indicating unsafe conditions or reports of fear or discomfort were included in the records reviewed.

Unsubstantiated: 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: 6 of 7

Control Number 11-AS-20260814083639

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 did not safeguard residents belongings.
It was alleged that the resident reported their personal journals were missing and believed her cell phone had been accessed without permission, leading the resident to believe their belongings and personal information were not being properly safeguarded.

Administrator Interview: On 08/17/2026 at 1:11pm, the Department interviewed A1 in regards to the allegation. A1 denied the allegation. A1 stated that R1 had not reported any missing journals or personal items. A1 described the facility’s process for locating or replacing missing items but confirmed that no such reports had been made by R1.

Staff Interviews: On 08/17/2026 between the hours of 9:31am - 2:15pm, the Department interviewed 7 staff in regards to the allegation. 6 out of 7 staff denied the allegation and stated they had not seen missing items and had never handled R1’s belongings 1 out of 7 staff did not confirm nor deny the allegation and indicated only being in R1’s room once and did not know whether items were missing

Resident Interviews: On 08/17/2026, between the hours of 9:46am - 1:39pm, the Department interviewed 9 residents in regards to the allegation. 4 out of 9 residents confirmed the allegation stated that belongings were missing such as clothing, money, and personal items. 5 out of 9 denied the allegation stated they had not had belongings go missing and had not observed unauthorized entry.

Records Review: On 09/04/2026 between the hours of 3:40pm–4:40pm, the Department conducted a records review and observed the following: The LIC 603 Preplacement Appraisal does not document missing belongings at admission. No written reports, logs, or facility documentation referencing missing journals, stolen items, or unauthorized handling of R1’s property were present in the records reviewed.

Unsubstantiated: 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)

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