198201010-2-24-2021-11-AS-MVAO-BYQNMA-20210302093449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 02/19/2021
Date Signed: 02/24/2021 10:47:22 AM

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
01/15/2021 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210115121304

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:	02/19/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Sherrina Lewis, Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident is restricted from setting the heating system in his room
Facility has not replaced a resident's dentures

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation 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.

The investigation consisted of following: Interviews and Record reviews. On 01/22/21, LPA Soto interviewed Administrator Sherrina Lewis. On 02/12/21, LPA Soto interviewed R#1 – R#7 and S#2 – S#7. LPA Soto received the following documents on 11/02/20 from administrator: Resident roster, Staff roster, 2 copies Client/Resident personal property and valuables list, and Admissions Agreement.

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: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

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-20210115121304

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: 02/19/2021

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following. For Allegation #1 –Resident is restricted from setting the heating system in his room. Interviews conducted with R#1 – R#7 and S#2 – S#7, stated that all the thermostats do have a cover over them, so no one can touch them accept staff. Interview with Administrator stated that they put the cover over the thermostats to avoid and prevent residents from changing the temperature in their own rooms because it doesn’t only affect that one resident’s room, it effects at least 2 to 3 other rooms temperature. One thermostat can control up to 4 rooms, so, if a resident’s changes the temperature in their own room, they will change the temperature in 2 to 3 other rooms. LPA Soto was aware and advised Administrator to put covers on the thermostats, in order to avoid and prevent residents changing their own room temperatures. Administrator, staff, and resident’s interviews do not concur with the above allegation.

Allegation #2 - Facility has not replaced a resident's dentures. Interviews conducted with residents #2 - #7, stated that they do not know of any resident’s losing their dentures. Interviews conducted with S#3 - S#7, stated that they are not aware of any resident losing or complaining about losing their dentures. Interview conducted with Administrator, stated that R#1, did report that R#1 dentures were thrown away by the housekeeper. The Resident’s personal property and valuables list in R#1 file, does not have dentures as part of R#1 personal property or valuables list. She also stated that she offered to help R#1 look for R#1 dentures and R#1 refused, R#1 wanted them replaced. Interview conducted with R#1, stated that he had placed R#1 lower dentures on his night stand and when R#1 went to get the dentures, they were not there. He believes the lower dentures were thrown away by the housekeeper as she was cleaning R#1 room. R#1 did not list the dentures on his personal and valuables list and R#1 takes care of his own needs. He manages his money, makes his own appointments, and provides his own transportation. R#1 will have to replace R#1 own dentures, the facility is not responsible for replacing his lost dentures. Administrator’s, resident’s, staff, and documents do not concur the above 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 allegations are unsubstantiated

A telephonic exit interview was conducted with Sherrina Lewis, Administrator, 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: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

LIC9099 (FAS) - (06/04)

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