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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201010
Report Date: 06/07/2021
Date Signed: 06/08/2021 09:33:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
198201010
ADMINISTRATOR:ESTELLA LEWISFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 54DATE:
06/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:52 PM
MET WITH:Michelle LopezTIME COMPLETED:
03:30 PM
NARRATIVE
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On June 7, 2021, at 2:52 PM. Licensee Program Analyst (LPA) Martessa Brown and Licensee Program Manager (LPM)Janae Hammond conducted an unannounced Case Management regarding infection control. LPA met with Lopez Administrator and disclosed the purpose of today Case Management.

During the today visit, LPA and LPM observed that facilities main entry did not have a reception area to screen visitors for covid at the point of entry.
  • LPA and LPM did not see observe visitors and employee sign in log.
  • Visitor/employee temperature checked point and records.
  • Hand sanitizer at main entry.
  • Covid Signs posted through out the facility



LPA and LPM discussed the corrections with the administrator to implement Mitigation Plan in the facility and adhere to current guidance regarding the CDC and PHD.

An exit interview was conducted and developed with the administrator. A copy of the report was given to the administrator.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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