198201010-5-7-2021-11-AS-JHAD-C44VKU-20210618163052

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 05/07/2021
Date Signed: 05/07/2021 04:29:37 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
10/28/2020 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201028150306

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:	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Sherrina Lewis, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Residents are not being provided a safe/sanitary environment.
Resident's care needs are not being met.
Facility is not safeguarding resident's belongings.

INVESTIGATION FINDINGS:

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On 5/7/21 at 4:00 PM Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent visit in order to render investigation findings for the above allegations. Due to the situation surrounding the coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation findings was conducted telephonically with Sherrina Lewis, the facility administrator.

The investigation consisted of the following: LPA Brown interviewed Sherrina Lewis on 11/6/20 and requested the following documents: LIC 500, Residents Rosters and incident reports. On 4/30/21, LPA Brown interviewed Residents R#2-R#6 and Staff S#1-S#6.

The investigation revealed the following: Regarding allegation #1, Residents are not being provided a safe/sanitary environment. On 11/6/20 LPA Brown Interviewed Administrator Sherrina Lewis, she stated there was no problems with the facility being clean. She stated housekeepers clean residents room on a daily basis. She stated no staff/residents mentioned any concerns.

LIC 9099-C is on the next page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

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-20201028150306

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: 05/07/2021

NARRATIVE

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Interviews conducted on 4/30/21 with residents R#2-R6, they stated do not have any problems with facility being clean and housekeepers clean every day. Interviewed staff S#1-S#6 they stated, facility is clean and housekeepers clean rooms daily. They stated have not heard any complaints from residents.

Allegation #2, Resident’s care needs are not being met: Interview conducted with Administrator on 11/6/20. She stated that was not true and residents needs are being met. She stated residents have a call button and caregivers will come to assist. She stated no residents/staff have not mentioned any concerns. Interviews conducted on 4/30/21 with residents R#2-R6. They stated do not have any problems with receiving help from staff and no other residents mentioned any concerns to them. Interviewed staff S#1-S#6 they stated residents are assisted every day and have a call button for assistance. They stated have not heard any complaints from residents.

Allegation #3, Facility is not safeguarding resident's belongings: Interview conducted with Administrator on 11/6/20, she stated there was no recent report of a residents missing a cane. She stated resident’s belongings are safeguarded and locked in their rooms. Interviewed residents R#2-R#6, they stated have no problems with their belongings being missing. They have not heard any complaints from other residents. Interviewed staff S#1-S#6, staff stated there has been no concerns with residents having missing belonging but some residents forget where they leave belongings. They stated no residents/staff have reported any concerns. LPA was not able to interview resident R#1 due to no longer being at the facility. Regarding investigations, Interviews conducted with Administrator, residents and staff, do not support the above allegations.

Although the allegations 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: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2021

LIC9099 (FAS) - (06/04)

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