198201010-7-30-2021-11-AS-MVAO-C68T9K-20210825143204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 07/29/2021
Date Signed: 07/30/2021 03:30:19 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
04/19/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210419162515

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: 48	DATE:	07/29/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Yosef Hedvat		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is short staff.
Staff handling resident medications are not qualified.
Medications are given to the residents late.

INVESTIGATION FINDINGS:

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On 7/29/21 at 12:00 PM, Licensing Program Analyst (LPA) Martessa Brown conducted investigation to deliver findings for the complaint allegations listed above. LPA met with Yose Hedvatf, the Administrator.

Investigation consisted of the following: On 4/27/21 LPA Brown interviewed the AdministratorSherina Lewis. LPA conducted a Health and Safety Check. LPA requested copies of: Staff/Resident Roster, staff time sheets for 4/16 & 4/17/21, medical technicians training procedures and any incident reports related to the above allegations.

Allegation: Facility is short staff

On 4/19/21 LPA interview Resident R1 regarding the above allegation, R1 stated there was only 2 staff available on 4/16/21 & 4/17/21. R1 stated facility is always short staff. On 4/27/21 LPA interview the administrator regarding the above allegation, she stated on 4/16/21, she was on duty, LVN and Medical Technician was working that day.
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: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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-20210419162515

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: 07/29/2021

NARRATIVE

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On 4/27/21 LPA interview the administrator, she stated there has not been any incidents with medication given late and has not heard any concerns. On 4/19/21 LPA interview Resident R1 regarding the above allegation, resident stated medication was administered 2-3 hours late. On 5/5/21 LPA interview residents R2-R5 stated there was no problems with receiving medication late. On 6/7/21 LPA interview Staff S-S4 regarding the above allegation, staff stated there has been no problems with medication given late. LPA interview S5, stated 3 or 4 months ago there was a problem, but they don’t have one anymore.

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 Yosef, 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: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20210419162515

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: 07/29/2021

NARRATIVE

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She stated on 4/17/21 there was 1 LVN AM/PM shift. On 4/19/21 LPA interview Residents R1, stated facility was short staff on 4/16/21 & 4/17/21 and there were only 2 staff on duty. On 5/5/21 LPA interview Residents R2-R4 regarding the above allegation, residents stated they had no problems with facility being short staff and no concerns. LPA interviewed R5 regarding the above allegation, resident stated facility is short staff on the weekend. LPA interview R6, stated staff is short staff in the evenings and not available around 6:30 pm-7:30 pm. On 6/7/21 LPA interview staff members S1-S4 regarding the above allegation, staff stated there is no problem with facility being short and has not heard any complaints. LPA interview S5 and staff stated they were short in the of April, but they have enough caregivers now. On 6/7/21, LPA met with new administrator and during meeting, she stated had to leave and give residents insulin but stated she was an LVN. On 7/14/21 LPA reviewed staff time sheets and facility had enough staff on 4/16 & 4/17.

Allegation: Staff handling resident medications are not qualified

On 4/19/21 LPA interview Resident R1, regarding the above allegation, R1 stated noticed a discrepancy with medication. R1 stated was not given the right medication and asked for another staff. On 4/27/21 LPA interview the administrator, she stated med techs are qualified to give residents pill medications, update and sign medication logs. On 5/5/21 interview Residents R2-R6 regarding the above allegation, residents stated they had no problems with staff handling their medications. LPA interview S1-S5 regarding the above allegation, staff stated there is no problem with staff being qualified to handle resident’s medication.

Medications are given to the residents late

On 4/19/21 LPA interview Resident R1 regarding the above allegation, R1 stated medication was administered 2-3 hours late.

LIC 9099-C is on the next page

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC9099 (FAS) - (06/04)

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