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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201010
Report Date: 10/12/2021
Date Signed: 10/13/2021 01:34:32 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
198201010
ADMINISTRATOR:ESTELLA LEWISFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 45DATE:
10/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Katherine Trevino-Wellness DirectorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Katherine Trevino, Wellness Director and Yousef Hedvat Administrator and the purpose of today’s visit was explained. The facility is a Residential Care for the Elderly, licensed to serve 136 Ambulatory and Non-Ambulatory which may be 10 hospice residents. developmentally disabled clients (age 18-59).

LPA and staff toured the physical plant along with Trevino, starting with the 1st floor consisted of the kitchen area was inspected. LPA enough perishable and non-perishable food available which is stored properly. 2nd floor, LPA observed resident’s rooms, small kitchen area and activity room. LPA did not observe enough Covid-19 signs posted in the activity rooms, storage room was full of PPE supplies and housekeeping/maintenance room was inspected. 3rd floor, LPA observed residents’ rooms, Lunch room with kitchen was inspected. All facility floors had adequate lighting throughout the facility. Walls and floors were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were were clean and operational. The water temperature measured restrooms water temperature on the 2nd floor measured at 85 F and 2nd floor 87 F. LPA spoke to Trevino and informed water temperatures should be 105-120 Fahrenheit. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean during the time of visit. Fire extinguishers was charged, smoke detectors and Carbon Monoxide were operable.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing stations ( Located in common areas and restrooms). LPA observed staff and some residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA was unable to complete visit and will come back to the facility.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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