198201010-8-20-2021-11-AS-JHAD-C8CSGQ-20211101135215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 08/19/2021
Date Signed: 08/20/2021 08:04:56 AM

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
08/19/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210819101335

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: 47	DATE:	08/19/2021
		UNANNOUNCED	TIME BEGAN:	04:33 PM
MET WITH:	Yosef Hedvat		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Facility elevators are in disrepair

INVESTIGATION FINDINGS:

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On 8/19/21 at 4:30 PM Licensing Program Analyst (LPA) Martessa Brown, conducted a visit to initiate a complaint investigation for the above allegation. LPA met with Administrator Yosef Hedvat and the purpose of today visit was explained.

During today’s visit investigation consisted of the following: On 8/19/21 LPA conducted a 10-day health & safety check visit. LPA toured the facility with the administrator and conducted Interview with administrator, staff #1 and resident.
Investigation revealed the following:

Facility elevtors are in disrepair

LIC 9099-C is on the next page.

Substantiated

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: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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-20210819101335

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: 08/19/2021

NARRATIVE

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On 8/19/21 LPA conducted interview with administrator, he stated the elevator was down on 8/18/21 due to some difficulties and technician had turn off in order to fix. He stated doesn't really no how long it was not operating. He stated received a call later that night by staff and informed him the elevator was not working. He stated the elevator was down at 11:30 PM. He stated the elevator was down until the technician came out on 8/19/21 in the morning. He stated staff called 911 that night and the fire department came out to the facility. LPA interviewed staff #1 (S1) stated the elevator was down yesterday at 8:30 AM. S1 stated there was a resident that was upstairs waiting to come downstairs. S1 stated the elevator started back working in the afternoon. LPA conduced interview with R1 he stated elevator was down all day.

Substantiated: Based on Investigators interviews which were conducted with Administrator, Staff and resident the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 Division (6) and Chapter (8) are being cited on the attached LIC9099-D.

An exit interview was conducted with Yosef Hedvat and a hard copy was provided and Appeal Rights provided.

See LIC 9009-D 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: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210819101335

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: 08/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/19/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Administrator will make sure both elevators are in good condition and working at all times. Administrator will submit a plan on how they will ensure that the residents health and safety in the event if the elevators are down and notify licensing when the incident has occurred to LPA Brown by 8/20/21.
	8 9 10 11 12 13 14	Based on interviews conducted, Licensee did not ensure both elevators were accessible to residents in care. Administrator did not notify LPA that elevators was not in operations. This an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC9099 (FAS) - (06/04)

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