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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201010
Report Date: 10/18/2021
Date Signed: 10/19/2021 09:20:18 AM

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: 47DATE:
10/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Katherine Trevino and Yousef HedvatTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/18/21, Licensee Program Analyst (LPA) Martessa Brown conducted an unannounced Health and Safety visit to the above facility. LPA met Trevino and Hedvat and disclosed the purpose of today’s visit.
  • On 10/12/21 (LPA) Martessa Brown was at the above facility. LPA toured the facility and there were 3 residents rooms that uses oxygen tanks. LPA observed there was no Oxygen warning signs on none of those residents door.
  • Administrator has not been sending incident reports to CCL regarding R1's behavior. LPA was sent incident reports later than the occurrence of R1's behavior.

During today's visit the following deficiencies are being cited on the next page on LIC 809-D

During today’s visit LPA discussed the with the Administrator plan of corrections and due dates. Deficiencies cited on California code of regulations title 22, division 6, chapter 8.

An exit interview was conducted and a copy the report and the appeal rights were discussed and provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2021
Section Cited

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87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
This requirement was not met as evidence by:

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On 10/12/21 Based on LPAs interviews conducted, 3 residents with use of oxygen tanks did not have signs posted on the door. Administrator should have the knowledge to follow administrator duties.
This poses and immediate or potential risk health & Safety risk to residents in care.
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Type B
10/25/2021
Section Cited

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87211 Reporting Requirements
a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
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Based on LPAs interviews conduct, Administraor has not submitted all incident report regarding R1s.
This poses and immediate or potential risk health & Safety risk to residents in care.
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Administrator will review regulation in Title 22 and Administrator will send a statement that he understood the regulation on reporting requirements to LPA's attention by POC due date 10/25/2021.
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: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2021
LIC809 (FAS) - (06/04)
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