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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201010
Report Date: 06/09/2021
Date Signed: 06/10/2021 04:33:31 PM

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:
06/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michelle Lopez-AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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On June 9, 2021 at 2:00 PM . Licensee Program Analyst (LPA) Martessa Brown conducted an unannounced Health and Safety visit to the above facility. LPA met with Lopez, the Administrator and disclosed the purpose of today’s visit.

On June 7, 2021 (LPA) Martessa Brown and (LPM) Janae Hammond was at the above facility. LPA and LPM was touring the physical plant and inspected the facility elevators. LPA observed 1 out of two elevators were not in use for residents and staff. Administrator confirmed both elevators were not working last week and only 1 of them was able to be used. Administrator did not report to CCLD both elevators were not in service. LPA/LPM conducted interview with Administrator she stated she is currently taken classes at this time to obtaining her Administrator Certificate and there is no designated substitute. LPA/LPM also observed while Administrator-Michelle was on duty as administrator was going to administering insulin to resident’s due to no LVN/RN's at the facility but she stated has her RN License.

During today’s visit LPA discussed the with the Administrator plan of corrections and due dates. Deficiencies cited on California code of regulations title 22, division 6, chapter 8.

An exit interview was conducted and a copy the report and the appeal rights were discussed and provided to Administrator-Lopez.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2021
Section Cited

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Personnel Requirements – General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more...

requirement was not met as evidenced by:
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On 6/7/21 LPA observed while administrator was on duty she was also administering insulin to residents in care due to no qualified personnel available.
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Type B
06/30/2021
Section Cited

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Reporting Requirements:
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified ...

This requirement is not met as evidence by:
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On 6/7/21 LPA interviewed Administrator Michelle Lopez and she stated did not complete incident report. CCLD was not notified two elevators were not working in the facility. One of the elevators are not in use.
This possess a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2021
Section Cited

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Administrator - Qualifications and Duties:
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the...
requirement was not met as evidenced by:
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On 6/7/21 LPA interviewed Administrator Michelle Lopez. She stated was in the process of obtaining her Administrator Certificate. There is also no designated substitue Administrator for the facility.
This possess a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3