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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 07/20/2021
Date Signed: 09/14/2021 05:07:52 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
06/03/2021 and conducted by Evaluator Martessa Brown
COMPLAINT CONTROL NUMBER: 11-AS-20210603150359
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: 51DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Yosef Hedvat, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility in Disrepair
INVESTIGATION FINDINGS:
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On 7/20/21 at 2:34 PM, Licensing Program Analyst (LPA) Martessa Brown conducted investigation to delver findings for the complaint allegation listed above. LPA met with Yosef, the Administrator.

Investigation consisted of the following: On 6/7/21 Licensing Program Analyst (LPA) Martessa Brown and Licensing Program Manager (LMP) Janae Hammond conducted a Health & Safety. LPA Brown LPA Brown Interviewed the Administrator Michelle Lopez: Toured facility physical plan, LPA checked 1st floor main entrance elevator. LPA and LPM were able to take elevator to the 2nd floor that consisted of assisted living non-Ambulatory residents. The 3rd floor consisted of Ambulatory residents. LPA inspected the dining room. LPA conducted interviews with administrator, 4 staff and 5 residents.

On 6/7/21 LPA interview the administrator, she stated both elevators were down since last Thursday for 2-3 hours and the 2nd elevator is still not working. She stated ambulatory resident are located on the 2nd floor and non-ambulatory are the 3rd floor. She stated staff were able to take food trays to non-ambulatory residents on 3rd floor even though elevators were down. She also stated if residents needed leave, they can use the emergency ramp.
LIC 9099-C is on the next page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20210603150359
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: 07/20/2021
NARRATIVE
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 On 6/7/21 LPA interview staff #1 regarding the allegation, staff stated both elevators were down. staff stated 1 of the elevators was down for 2-3 hours. Staff stated the 2nd elevator is still not working due to waiting on inspection and has been not working since 01/21. On 6/7/21 LPA interview staff 2-3 regarding the allegation, they both stated both elevators were down. They stated one elevator was down for only a short period but the 2nd elevator is still not working. They stated staff were able to bring residents their food. On 6/7/21 LPA interview staff 4 regarding the allegation, staff stated heard about the elevators not working but always take the stairs. On 6/7/21 LPA interview residents 1-5 regarding the allegation, residents stated one of the elevators has been down for a long time. They stated the 2nd elevator was down around 3/21 but has been working.

Based on LPA and LPM observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

A telephonic exit interview was conducted with Yosef, Administrator and a hard copy was provided via email for signature and Appeal Rights provided.

See LIC 9009-D on the next page.


SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20210603150359
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include services and procedures for the safety and well-being of residents This requirement was not met as evidenced by:
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Licensee will make sure both elevators are in good condition and working at all times. Licensee will submit proof to LPA Brown that elevators are operating by 8/3/21, to ensure the health and safety of residents in care.
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Based on observation and interviews conducted, Licensee did not ensure that both elevators were accessible to residents. Elevator # 1 was down for several hours and elevator #2 continues to be inoperable. This poses a potential Health & 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: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3