198201010-8-6-2021-11-AS-JHAD-C5V4CQ-20210813185930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 08/05/2021
Date Signed: 08/06/2021 10:28:17 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
08/04/2021 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210804112017

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: 47	DATE:	08/05/2021
		UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Yosef Hedvat		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Staff neglect resulting in resident developing pressure injuries.
Resident is dehydrated.

INVESTIGATION FINDINGS:

1
2
3
4
5
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7
8
9
10
11
12
13

On 08/05/2021, Licensing Program Analyst (LPA) Ulysses Coronel initiated an unannounced 24-hour Complaint Investigation Visit to this facility. LPA met with Administrator Yosef Hedvat and the purpose of the visit was explained.
The investigation consisted of the following: During todays visit LPA and administrator conducted a tour of the facility. LPA reviewed facility records and conducted interviews with the administrator and five staff. The investigation revealed the following: During today's visit, a review of the facility's resident roster and resident discharge list from June 2021 to present indicate that R1 is not a resident at this facility. During todays visit the administrator and 5 out of 5 staff stated that R1 is not a resident at this facility. The administrator stated that R1 was a resident at "Country Villa Terrace Nursing Center" next door. This agency has investigated the complaint alleging "Staff neglect resulting in resident developing pressure injuries." and "Resident is dehydrated.". We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.
No deficiencies cited. An exit interview was conducted and a copy of this report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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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