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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 05/12/2022
Date Signed: 05/12/2022 05:59:16 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
10/12/2021 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211012081935
FACILITY NAME:COUNTRY VILLA TERRACE ASSISTED LIVING CENTERFACILITY NUMBER:
198201010
ADMINISTRATOR:ESTELLA LEWISFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 55DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Clarizze PunitTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff do not meet the incontinence needs of resident.
INVESTIGATION FINDINGS:
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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 Punit, the Administrator and the purpose of visit was disclosed.

Investigation consisted of the following: On 10/12/21 LPA met with the administrator Yosef Hedvat and Wellness Nurse Katherine Trevino regarding the complaint. LPA obtained the following documents staff & residents roster, staff file. Incontinent training/protocol. LPA interviewed residents #1-6 and staff members #1-4.

Investigation revealed the following:

Staff do not meet the incontinence needs of resident.
LIC 9099-C is on the next page.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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-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: 05/12/2022
NARRATIVE
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On 4/14/22, LPA Brown interviewed Clarizze Puit, assistant administrator regarding the above allegation. She stated staff changes incontinent residents every 2 hours. She stated, some residents may be changed more frequently if they use the call button. She stated, 4 caregivers are available to assist residents with changing needs, 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 not being change timely. Staff stated on some occasion if a resident is sleeping well at night, the resident doesn't like to be awaken. Based on interviews and documentation received the allegation is unsubstantiated.

Exit interview was conducted with Clarizze Punit and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2