198201010-8-7-2020-11-AS-EMAZ-BV3UEZ-20201105143154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 08/07/2020
Date Signed: 08/07/2020 04:47:12 PM

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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2020 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20200727141538

FACILITY NAME:	COUNTRY VILLA TERRACE ASSISTED LIVING CENTER		FACILITY NUMBER:	198201010
ADMINISTRATOR:	PADAMA, ANTHONY		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS:	DATE:	08/07/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:			TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident was in altercation with another resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Cifuentes initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Sherrina Lewis, the facilities administrator.

The investigation consisted of the following:
LPA Cifuentes conducted a facetime video call with the residential care director. During the call, LPA spoke with residential care director, was shown dining room, kitchen, lounge, patio's and client rooms. LPA requested the following documents: client and staff rosters and a staff schedule.

Continues on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020

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-20200727141538

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
MONTERY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 08/07/2020

NARRATIVE

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Regarding the allegation: Resident was in altercation with another resident.

The investigation revealed the following:

On 8/4/2020 LPA Cifuentes toured facility. LPA was shown dining room, kitchen, lounge, patio's and client rooms. LPA was told by staff that if physical client on client fights occur, the police will be called in as that behavior is not allowed by the facility. If staff notice that clients are verbally arguing they separate them and report it to management. If roommates are not getting along, the facility staff will move them to wear there might be a better fit.

On 8/6/2020 and 8/7/2020 LPA interviewed residents 1 through 6. Of the resident’s interviewed 6 out of 6 stated they had not gotten into a physical altercation with another resident, and 5 out of 6 stated they had not seen other residents get into more than verbal arguments.

On 8/6/2020 LPA Cifuentes interviewed facility staff. 6 out of 6 staff stated that they had seen not seen residents getting into physical altercations.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of the report was emailed to Sherrina Lewis, Residential Care Director.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020

LIC9099 (FAS) - (06/04)

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