198201010-4-15-2022-11-AS-JHAD-CELQJH-20220520121242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 04/14/2022
Date Signed: 04/15/2022 10:09:10 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210510082426

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: 56	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Clarizze Puit		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's diapering needs are not being met.
Resident's showering needs are not being met.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today's visit LPA met with Clarizze Puit, the Administrator and the purpose of visit was disclosed.

Investigation consisted of the following: On 5/17/21 LPA Brown met with Marisol Ortega, Medical Technician and conducted a Health & Safety check. LPA requested the following documents at the time of visit: Staff/Resident Roster, most recent incident reports related to the above allegations, a list of residents that are incontinent, staff training records and staff incontinent schedule. On 4/6/22, LPA Brown met with Clarizze Puit and obtained the following documents: LIC500, Resident Roster, Shower/Care Staff Schedule. LPA reviewed the facility Plan of Operation and obtained copies of the personal care and Incontinent care plan. LPA conducted interviews with Residents #1-5 and Staff members #1-3. On 4/13/22 LPA interview remaining staff member #4-6.
LIC 9099-C is on the next page.

Unsubstantiated

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: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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 3

Control Number 11-AS-20210510082426

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: 04/14/2022

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: Resident's diapering needs are not being met.

On 4/14/22, LPA Brown interviewed Clarizze Puit, assistant administrator regarding the above allegation. She stated staff changes residents every 2 hours but may vary. She stated, may be changed more frequent, if a resident uses the call button. She stated they have 4 caregivers available to assist residents but on some occasions staff may call out. On 4/6/22, LPA Brown interviewed residents #1-5 all residents stated they do not have any problems with staff meeting their changing needs. Residents also stated they have not heard any complaints regarding other residents needs not being met. On 4/6/22 and 4/13/22, LPA Brown interviewed Staff members #1-6. They stated residents are change every 2 hours. Staff also stated do not have any concerns that residents are not being change timely. Staff stated on some occasion if a resident is sleeping well, the resident doesn't like to be awaken.

Regarding the allegation: Resident's showering needs are not being met.

On 4/14/22, LPA Brown interviewed Clarizze Puit, assistant administrator regarding the above allegation. Administrator stated any residents who needs assistant are given showers and bed baths 2-3 times a week. She stated some residents like to take showers more often and staff will assist them. She stated only one resident has complained to her and they are addressing the residents needs. She stated staff has a shower schedule that they check at the beginning of their shift. She also mention was in the process of updating shower schedules. On 4/6/22, LPA Brown interviewed residents #1-5 and all residents stated they are given showers 2-3 times a week. They stated do not have any concerns with staff giving them a shower and haven’t heard any complaints.

LIC 9099 is 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: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210510082426

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: 04/14/2022

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

On 4/6/22 and 4/13/22, LPA Brown interview Staff member #1-6. They stated residents are given showers and bed baths 2-3 times a week. They stated the shower schedule is posted for them to view and initial. They stated the only concerns that may arise is when a resident refuse to take a shower. Staff stated they will inform the administrator.

During investigation, LPA Brown reviewed the plan of operation incontinent needs care plan, shower schedule, timesheets and staffing policy.

Based on interviews and documentation during the investigation Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

A telephonic exit interview was conducted with Administrator, and a hard copy was provided for records.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3