198201010-5-12-2022-11-AS-MVAO-CFFS87-20220616133841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 05/12/2022
Date Signed: 05/12/2022 05:46:48 PM

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

PUBLIC

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: 55	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Clarizze Punit		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not properly clean and sanitize facility surfaces.
Facility outdoor gate is not kept closed to protect the safety of residents.

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 staff and resident roster. Incontinent training/protocol. LPA interviewed residents #1-6 and staff members #1-6.

Investigation revealed the following:

Staff do not properly clean and sanitize facility surfaces.

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: 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)

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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 4/28/22 and 5/12/22, LPA Brown interviewed administrator regarding complaint allegation. She stated maintenance handles housecleaning schedule and how often they clean. She stated doesn’t have a copy of the housekeeping schedule to provide. She stated housekeeping clean residents bedrooms daily except when some refuses. She also stated they have 1 housekeeper and are looking to hire more help. LPA interviewed staff members #1-6, there has been multiple times when there is no housekeeper on the weekends. Staff also stated if housekeeping calls out, they have to step in and clean. Also, staff stated they have not been trained on how to disinfect high surfaces areas since 2020. residents #1-6, stated housekeeping cleans during the week but they do not have a housekeeper on the weekends. LPA also requested a housekeeping schedule and one was not provided. Based on interviews conducted the above allegation is substantiated.

Facility outdoor gate is not kept closed to protect the safety of residents.

On 10/12/21 LPA conducted interview with Yosef Hedvat and Wellness Nurse Katherine Trevino regarding the above allegation. They both stated the facility door was left open due to having a problem with the security alarm system. They stated the gate was unable to close and therefore had to remain open all day. LPA arrived at the facility and the gate was open, with no one supervising the entry. Based on interviews and observation the above allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

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: 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 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: 05/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/24/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents.. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will come up with a plan on how they will ensure there is enough housekeepers daily, cleaning schedule and routine disinfecting the premises. Licensee will provide to LPA by 5/24/22.
	8 9 10 11 12 13 14	Based on observation and interviews conducted, staff and residents stated on multiple occasion there has not been a housekeeper. Staff also stated common areas are not routinely disinfected. This is a potential health and safety risk to clients in care.	8 9 10 11 12 13 14
Type B 10/12/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents.. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator corrected and closed gate to ensure it would remain lock during the date of visit POC was cleared.
	8 9 10 11 12 13 14	Based on observation and interviews conducted, staff stated the building gate was left open due to alarm system not working. This is a potential health and safety risk to clients in care.	8 9 10 11 12 13 14

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: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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