198201010-10-1-2020-11-AS-AJKK-BU2NPK-20201003103825

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 09/30/2020
Date Signed: 10/01/2020 03:46:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/16/2020 and conducted by Evaluator Jennifer Jones

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200916120421

FACILITY NAME:	COUNTRY VILLA TERRACE ASSISTED LIVING CENTER		FACILITY NUMBER:	198201010
ADMINISTRATOR:	ESTELLA LEWIS		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS: 58	DATE:	09/30/2020
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sherrina Lewis, Wellness Director		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff yelled at resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Jones conducted a subsequent complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted with Sherrina Lewis, the facility Wellness Director.

During today's visit, LPA discussed the allegation with the Wellness Director, Sherrina Lewis. LPA requested a copy of the resident and staff roster and staff contact information.

On 10/01/20, LPA discussed the findings with the Wellness Coordinator, Sherrina Lewis.

The investigation revealed the following: For allegation(Staff yelled at resident) It was alleged that staff yell at resident in care. On 09/21/20, LPA interviewed residents 1-6. R1 revealed during the interview that staff 1 yelled at him in the parking garage while attempting to take his temperature. R1 stated that he has not

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20200916120421

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 09/30/2020

NARRATIVE

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experienced any other incidents of staff yelling at him. R2-R6 revealed during their interview that staff 1 has never yelled at them and is always nice and friendly. R2--R6 stated the other staff who work at the facility are nice too. On 09/30/20, LPA interviewed staff 1-7. Staff 1 denied the allegation and stated during his interview that he has not had a confrontation with any of the residents. Staff 1 said he always nice and speaks to all of the residents. Staff 2-6 stated that have not received any complaints about staff 1 from any of the residents. Staff 2-6 stated that they have never witnessed any staff yell at the residents.

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.

A tele-visit exit interview was conducted with Sherrina Lewis, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 516-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020

LIC9099 (FAS) - (06/04)

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