198201010-5-7-2021-11-AS-JHAD-C4EPQ4-20210628113031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 05/07/2021
Date Signed: 05/07/2021 04:27:28 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
04/05/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-NP-20210405094333

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: 53	DATE:	05/07/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Sherinna Lewis		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility did not safeguard 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 4/13/21 and requested the following documents: LIC 500, Residents Rosters and incident reports related to the above allegation. On 4/30/21, LPA Brown interviewed Residents R#1-R#6 and Staff S#1-S#6.

The investigation revealed the following: Regarding allegation, Facility did not safeguard resident's belongings. Interviewed Administrator she stated there was no report of missing belongings. She stated there was no report of a missing walker and resident has several walkers.
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-NP-20210405094333

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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She stated if items were missing the facility’s protocol is to look for the missing item and report on LIC form and compare resident’s inventory. She stated when residents away from rooms, staff will make sure they are locked. Interviewed residents R#1 stated she had purchased a walker and was missing from her room. She did not remember when. Resident also stated has a few walkers but not the one she had. Interviewed residents R#1-R#6, they stated have no problems with 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 belongings, but some residents forget where they leave belongings. They stated no residents/staff have reported any concerns. 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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