198201010-10-19-2021-11-AS-MVAO-CFFS89-20220616133842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 10/18/2021
Date Signed: 10/19/2021 09:57:10 AM

Substantiated

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
10/12/2021 and conducted by Evaluator Martessa Brown

COMPLAINT CONTROL NUMBER: 11-AS-20211012081935

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:	10/18/2021
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Katherine Trevino and Yosef Hedvat		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident smokes inside of facility where oxygen is in use.

INVESTIGATION FINDINGS:

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

On 10/18/21, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent visit in order to render investigation findings. During today’s visit LPA met with Kathryn Trevino, Wellness Director and Yousef Hedvat Administrator and the purpose of the visit was explained.

The investigation consisted of the following: On LPA toured the physical plants. LPA obtained residents roster, reviewed facility’s Plan of Operation and requested the following: #1-4 staff and #1-4 clients file, Incontinent training/protocol.

The investigation revealed the following: Interviews, records review and observations.

Regarding allegation: Resident smokes inside of facility where oxygen is in use.
On 10/12/21, LPA spoken to Trevino and Hevat, regarding the above allegation they both stated Resident #1 (R1) has been smoking in the marijuana inside the facility.
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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 11-AS-20211012081935

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: 10/18/2021

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

They stated R1 has been smoking in the bedroom and in the activity/tv room around other residents. Both stated R1 has been smoking for a couple of months. They stated have tried to direct R1 to go outside to smoke but wants to continue to smoke inside the facility. They have also received complaints from other residents that R1 has been smoking. They also stated R1 is smoking around residents with oxygen tanks. Trevino stated they have 3 resident that use oxygen tanks. On 10/18/21, LPA interviewed the Reporting Party (RP), stated resident smokes marijuana in the activity room with resident that have oxygen tanks often. LPA reviewed incident reports, stated R1 has been smokes in the activity room.

Based on LPA observations, interviews which were conducted and record review(s), 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 LIC 9099-D.

Exit Interview Conducted, appeal rights were explained, and a copy of this report was furnished.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20211012081935

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: 10/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/19/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by	1 2 3 4 5 6 7	Administrator will submit a plan on how he will ensure residents are safe and come up with a plan to ensure R1 is not smoking in the facility and read regulation in Title 22 section and send a statement that he read and understood regulation. . All information is due to LPA Brown by POC due date 10/19/21.
	8 9 10 11 12 13 14	Based on LPAs Interviews and document reviews. Administrator did not ensure that residents were to be comfortable and safe conditions while in care. R1 has been smoking inside the facility premises. There are also residents that use oxygen tanks. This is an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	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: 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

LIC9099 (FAS) - (06/04)

Page: 3 of 3