198201010-4-5-2022-11-AS-AJKK-CDM25C-20220418170520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 04/04/2022
Date Signed: 04/05/2022 08:11:50 AM

Unsubstantiated

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
03/30/2022 and conducted by Evaluator Jey Cardenas

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220330121032

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:	04/04/2022
		UNANNOUNCED	TIME BEGAN:	10:19 AM
MET WITH:	Clarizze Punit		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not prevent resident from engaging in inappropriate activities
Staff did not medically assess resident after incident
Staff did not safeguard resident's personal belongings
Staff did not notify resident of incident to his personal belongings
Staff did not notify proper authorities of incident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Jey Cardenas conducted an initial 10 day complaint investigation visit to the above facility to initiate investigation into the above mentioned allegations. LPA met with administrator, Yosef Hedvat and back up administrator, Clarizze Punit. LPA conducted covid-19 risk assessment, facility is clear of Covid-19 infection. LPA explained the purpose of the visit.

Investigation consisted of the following: interviews conducted with administrator, back up administrator, staff and residents. LPA reviewed and obtained copies of R2s Physician Report, Needs and services plan, and appraisal, and admission agrrement. LPA obtained copy of staff, and client roaster.

It is alleged that: EMT was called and transported resident to the hospital; R1s vehicle was left parked in the alley behind facility. R1s keys were left with R3. The staff were unwilling to move R1s vehicle to the garage parking, therefore R2 volunteered to move it. Staff#1 saw R2 was having trouble controlling the car, so Staff#1 drove the vehicle from the alley to the parking garage. It was noted that

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

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-20220330121032

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: 04/04/2022

NARRATIVE

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(continued pg2)
the vehicle parked next to R1s car had damages that matched damages on R1’s vehicle. R2 denies hitting anything during the time it was being moved in the alley. Staff denies hitting anything during the time the vehicle was being moved from the alley to the garage.

-Regarding: Staff did not prevent resident from engaging in inappropriate activities. RP indicates that R2 should have not been allowed to operate R1’s vehicle due to physical condition. On 4/4/2022 LPA Cardenas reviewed R2s physician report Resident has no dementia, none auditory or visual impairment, not confused or disoriented, able to follow instructions and able to leave facility unattended. During interview with R3 and Staff#1, they both indicated that R2 volunteered to move R1s vehicle. Staff#1 indicates that none of the staff asked R2 to move the vehicle. Staff#1 indicated that R2 refused to get out of the vehicle after resident was having difficulty operating it. R2 didnt want to allow Staff to move it from the alley to the garage until after a few pleas from staff.

-Regarding: Staff did not medically assess resident after incident- LPA interviewed R1, resident indicates that R2 denies hitting anything during the time resident was operating the vehicle. LPA interviewed R3 who denies that R2 hit anything during the time R2 was operating the vehicle. Sttaff#1 indicates that during the time R2 was operating the vehicle there was a loud noise as if there was some impact and the vehicle hit something. R2 broke really hard and staff could hear the tires against the pavement, Staff#1 saw R2 slightly move forward as if there was impact. Staff#1 indicates that R2 was asked if everything was okay, R2 indicated he was okay. LPA asked if staff confirmed that there was actual impact, Staff#1 is unable to confirm if there was any actual impact or damage to the vehicle, staff didn’t check the vehicle for damages during the time R2 operated vehicle.

-Regarding Staff did not safeguard resident's personal belongings, during interview with adminstratrator, it was indicated that if there is any damages/losses facility will discuss with resident. At this time R1 has not been available to sit down and discuss next steps. LPA was unable to find anything outlined in the admission agreement regarding damages to personal property such as vehicle. R3 indicated that the garage has signs posted that the facility is not liable for any damages.

-Regarding Staff did not notify resident of incident to personal belongings. On 4/4/2022 LPA interviewed R1 who indicates that facility didn’t notify of damages to vehicle, resident heard it from the owner of the vehicle that was parked next to R1s vehicle. LPA asked the date he was told about the damages, resident

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220330121032

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: 04/04/2022

NARRATIVE

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(continued pg 3)

couldn't recall. LPA interviewed administrator who indicates that R1 was notified about the damages soon as the resident was available which was on the next day when resident came back from the hospital.

-Regarding Staff did not notify proper authorities of incident. During interview with Staff#1 the incident was not reported to facility administrator nor back up administrator because it was not known that there was any damage sustained to R1s vehicle or the car parked next to R1s. Staff#1 became aware of the scratches on Tuesday when the owner of the parked vehicle reported it to the facility.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations(s) did or did not occur, therefore the allegations are unsubstantiated.

No deficiencies cited, Exit Interview conducted, and report given facility representative.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

LIC9099 (FAS) - (06/04)

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