198201010-9-17-2020-11-AS-EMAZ-BU6MG2-20201007093512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 09/17/2020
Date Signed: 09/17/2020 06:00:51 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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/24/2020 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20200724143259

FACILITY NAME:	COUNTRY VILLA TERRACE ASSISTED LIVING CENTER		FACILITY NUMBER:	198201010
ADMINISTRATOR:	PADAMA, ANTHONY		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS:	DATE:	09/17/2020
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:			TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff do not provide resident with assistance in a timely manner.
Facility staff is not meeting the resident's toileting needs.
Bathroom has sewage damage

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted via Facetime with Sherrina Lewis, the facilities administrator. LPA explained the purpose of this visit is to deliver findings regarding the complaints listed above.

The investigation consisted of the following: On 7/30/2020 LPA Campos conducted a video call with the maintenance supervisor Ray Cortez. During the call, LPA was given a tour of facility grounds and checked the food supply. LPA requested the following documents: staff roster, client roster, and staff schedule. On 8/4/2020 and 9/17/2020 LPA Cifuentes toured facility grounds. LPA Cifuentes requested and received the following documents: Physician’s report, Medication administration record and hospital discharge records for resident one (R1), incontinence care list, facility maintenance records and exterminator records.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

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 4

Control Number 11-AS-20200724143259

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
MONTERY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 09/17/2020

NARRATIVE

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Regarding the allegation: Facility staff do not provide resident with assistance in a timely manner

The investigation revealed the following:

On 8/4/2020 LPA Cifuentes toured facility grounds with staff via facetime.

On 9/10/2020 LPA was told by administrator Sherrina Lewis that caregivers carry radio’s to be aware of which residents need assistance and answer call lights.

On 8/6/2020 and 8/7/2020 LPA Cifuentes interviewed residents 1 through resident 7. Of the residents interviewed 3 out of 7 stated the facility staff assisted them in a timely manner, with 3 of the 6 declining to answer the question.

Staff were interviewed on 8/6/2020. 5 out of 6 staff stated they provided assistance to residents in a timely manner.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: Facility staff is not meeting resident’s toileting needs

The investigation revealed the following:

On 8/4/2020 LPA Cifuentes toured facility grounds with staff via facetime.

On 9/9/2010 LPA was informed by administrator Sherrina Lewis that staff complete three incontinence care changes per shift and also change residents as needed. Of the clients that have some type of toileting need, some need assistance with adult brief changes and some with using the bedside commode.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20200724143259

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
MONTERY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 09/17/2020

NARRATIVE

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On 9/9/2020 LPA Cifuentes reviewed facility incontinence care list.

On 8/6/2020 and 8/7/2020 LPA Cifuentes interviewed residents 1 through resident 7. Of the residents interviewed 1 out of 7 stated the facility staff assisted them with their toileting needs, the other 6 clients stated they did not need assistance with toileting.

Staff were interviewed on 8/6/2020. 5 out of 6 staff stated they provided toileting care to residents.

Regarding the allegation: Bathroom has sewage damage

On 9/17/2020 Administrator Sherrina Lewis informed LPA Cifuentes that there had been a leak in a resident bathroom that affected two bedrooms. Leak occurred on July 3, 2020 and was repaired shortly thereafter. Per maintenance supervisor he was called in that day, as it was a weekend, to start the repair.

On 8/4/2020 LPA Cifuentes toured facility grounds with staff via facetime. LPA did not see any water/sewage damage via the video call. On 9/17/2020 LPA conducted a second zoom video call with maintenance supervisor Ray Cortez and viewed communal bathrooms on the first and second floors as well as resident rooms that had been affected by the leak. Both rooms had new flooring to replace the rugs, and room where leak occurred also had been repainted and repaired. The communal bathrooms did not show any water or other damage to the walls or flooring. LPA did not view any damage to corridor outside of communal bathrooms.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20200724143259

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
MONTERY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 09/17/2020

NARRATIVE

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On 8/6/2020 and 8/7/2020 LPA Cifuentes interviewed residents 1 through resident 7. Of the residents interviewed 3 out of 7 stated their bathrooms had malfunctioned, but where promptly repaired.

Staff were interviewed on 8/6/2020. 5 out of 6 staff stated toilets had broken, but 6 out of 6 stated there was no sewage damage, and 4 out of the 6 stated they believed the facility to be clean and in good repair.

Exit interview conducted, and a copy of the report was given to Sherrina Lewis, Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 4