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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201010
Report Date: 06/09/2022
Date Signed: 06/20/2022 10:28:28 PM


Document Has Been Signed on 06/20/2022 10:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
198201010
ADMINISTRATOR:ESTELLA LEWISFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 52DATE:
06/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:LaDonna WorthingtonTIME COMPLETED:
05:00 PM
NARRATIVE
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On 6/9/22, LPA Campos conducted a case management visit for Country Villa Terrace Assisted Living Center. LPA was allowed entry into the facility by LaDonna Worthington, LVN. LPA explained to Ms. Worthington, the purpose of the visit. During complaint investigation 11-AS-20220601152817, conducted on 6/9/22, LPA was informed by Administrator Carrisa Punit, that an Unusual Incident Report, LIC 624 for R1 medication error was not reported to Department of Social Services Community Care Licensing .

On 6/9/22, at 1:59 pm, LPA was informed by Administrator Carrisa Punit, that an Incident report LIC 624 Unusual Incident Report, was not submitted to Department of Social Services Community Care Licensing, for June 1, 2022, R1 Medication Incident.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conducted and a copy of the appeal rights were given at the time of the visit.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2022 10:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2022
Section Cited

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87211Reporting Requiremets(a)(1)(D)Reporting Requirements(a) ...(1) A written report shall be submitted to the licensing agency(D)Any incident which threatens the welfareety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

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Based on interviews, and record review, the licensee did not submit LIC 624 for R1 medication incident on 6/1/22. LPA was informed by Administrator on 6/9/22, 1:59pm, that a LIC 624 was not submitted to DSSCCL, which posed a potential health risk to residents in care.
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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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
LIC809 (FAS) - (06/04)
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