198201010-9-21-2020-11-AS-JHAD-BU92N3-20201009173205

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 09/09/2020
Date Signed: 09/21/2020 03:02:40 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
08/05/2020 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200805113445

FACILITY NAME:	COUNTRY VILLA TERRACE ASSISTED LIVING CENTER		FACILITY NUMBER:	198201010
ADMINISTRATOR:	PADAMA, ANTHONY		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS: 64	DATE:	09/09/2020
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sherrina Lewis, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff are not dispensing medication appropriately
Facility staff yells at a resident
Staff failed to meet residents' needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Sherrina Lewis, the facility administrator.

Based on the LPA's investigation, the investigation revealed the following. For Allegation #1 – Staff are not dispensing medication appropriately. LPA Soto reviewed the Medication Mars Log for R#1 for the months of July & August. The Mars showed that all medication was dispensed daily and as prescribed by the Doctor. There were no missed doses of medication for R#1 during the alleged months.

For Allegation #2: Facility staff yells at a resident. LPA Soto interviewed R#2 -R#7 on 09/01/20 @ around 11:30. They all stated that the staff does not yell or scream at any of residents, the staff treats the residents good. R#4 &

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

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-20200805113445

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: 09/09/2020

NARRATIVE

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R#5 also stated that they only people that yell all the time and are constantly arguing are R#1 & R#2, they are a nuisance. R#1 & R#2, have sense stop arguing and yelling, they have been getting along.

For Allegation #3 Staff failed to meet resident’s needs. LPA Soto interviewed R#1 on 08/11/20 & 09/01/20, R#1 stated that R#1 had requested to be moved to another room, in order to avoid arguments with R#1 roommate R#2, the facility failed to move R#1 and R#1's belongings. LPA Soto interviewed Administrator on 08/11/20 & LVN, Nerveza on 09/01/20, they both stated that they were trying to relocate R#1 to another room about 6 weeks ago and R#1 refused to be moved, R#1 did not give a reason, just refused to be moved, R#1 stated that R#1 was fine in R#1 current room. LPA Soto on 09/01/20, re-interviewed R#1, R#1 stated that the facility did offer to move R#1, but the room was too small, that’s why R#1 refused. R#1 agreed to move to another room, in order, to settle the arguing between R#1 & R#1's roommate. Facility will move R#1 and R#1 belongings, to another room equivalent in size to R#1 current room.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated

telephonic exit interview was conducted with Sherrina Lewis, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020

LIC9099 (FAS) - (06/04)

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