198201010-2-24-2021-11-AS-MVAO-BYQP6Z-20210302100310

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 02/19/2021
Date Signed: 02/24/2021 11:40:31 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
01/26/2021 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210126150256

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:	01:00 PM
MET WITH:	Sherrina Lewis, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facilities heater is in disrepair
Staff did not keep facility at a comfortable temperature for residents in care
Food is not of the quality and in the quantity necessary to meet the needs of the residents58

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 02/04/21, 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 02/13/21 from administrator: Resident roster, Staff roster, menu, 2 weeks of food order invoices, repair and new purchase of HVAC invoices.

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-20210126150256

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 - Facilities heater is in disrepair Allegation #2 - Staff did not keep facility at a comfortable temperature for residents in care. Interviews conducted with residents #2 - #7, all stated that their rooms where a little cold, but room temperature was comfortable. They were not aware that the heater was broken. Interview’s conducted with S#2 – S#7, all stated that they had not heard of anyone complaining about the room temperature, but they did know that the heater was not working. The facility was taking care of the problem. The administrator stated that 2 HVAC units were not working. They replaced HVAC unit #6 and repaired HVAC unit #7. The HVAC were not working for about 2 to 3 weeks. LPA Soto visually inspected the HVAC units, they are now in working order, HVAC units are working perfectly. The interviews and documents did not concur with above allegations.

For Allegation #3 - Food is not of the quality and in the quantity necessary to meet the needs of the residents. The menus and food order invoices show that the facility does provide a balance and nutritional food. They provide protein, vegetables, fruit, dairy, and grains in their meals. Residents #2, #3, #5, and #6 did state that the portions are too small. Interviews conducted with R#2 – R#7, all stated that they like the food the facility provides for all three meals. Interviews conducted with S#1 – S#7, stated that they believe that all the meals the facility serves are balanced and nutritious. They haven’t heard residents complain about the food. Residents #1, R#4, and R#7 stated that the portions are fine. Facility should provide bigger portions for those residents that request it. The interviews and documents did not concur with above allegations.

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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