198201010-4-12-2022-11-AS-UCOL-CEHS2S-20220517133002

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:39:20 PM

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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2022 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220322134440

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:	0	CENSUS: 55	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	09:46 AM
MET WITH:	Clarizze Punit		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to follow physician's orders.
Facility is not properly derstroying expired medications.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 04/12/2022 Licensing Program Analyst (LPA) Antonia Alvizar and Licensing Program Manager (LPM) Ulysses Coronel conducted a subsequent complaint investigation on the above allegations and met with, Assistant Administrator Clarizze Punit and administrator Yosef Hedvat and the purpose of the visit was explained.

The investigation consisted of the following: 03/30/2022 LPA Antonia Alvizar and Licensing Program Manager (LPM) Angela Kendrick obtained a copy of the current residents roster, staff roster and facility sketch. LPA and LPM tour the physical plant with assistant administrator, interviewed assistant administrator, 4 out of 55 residents and 5 staff. On 04/12/2022 LPA Alvizar and LPM Coronel interviewed 2 out of 55 residents and 4 staff. On 04/12/2022 LPA Alvizar reviewed residents R3, R4, R5 and R6 medications, medication administration records, centrally stored medication and destruction record and print out of doctors orders.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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 2

Control Number 11-AS-20220322134440

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: 04/12/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following: Regarding the allegation “Facility failed to follow physicians orders” During interviews conducted, 3 out of 6 residents agree with the allegations. On 03/30/2022 R#3 stated , “I have missed my medication Med-Tech’s get this half the time wrong except for today” 3 out of 6 residents disagree with that allegation. On 04/12/2022 resident R#5 stated, “ They follow the doctor’s order and hey make sure that I…..get my medications” 1 out of 9 staff agreed with the allegations, on 04/12/2022 staff S9 stated “Due to lack of guidance and support from the previous administration, discontinue (DC) orders were not being followed.” 8 out of 9 staff disagreed, staff S8 stated “Whenever primary physician makes (medication) order changes they notify the residents responsible party first, and sometimes there is a delay in the facility getting notified by the responsible party.” Record reviews the medication administration records (MARs) indicate that medications in the month of April are being administered per physicians orders. Regarding the allegation “Facility failed to follow physicians orders” “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

Regarding the allegation: “Facility failed to properly destroyed expired medications.” On 04/12/2022 LPA Alvizar reviewed residents R3, R4, R5 and R6 medications and MARs and did not observe expired medications present in the medication cart. Regarding the allegation: “Facility failed to properly destroyed expired medications.”Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”

No deficiencies where cited during today’s visit. An exit interview was conducted and a copy of this report was provided to Clarrize Punit, Assistant Administrator.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2