198201010-6-10-2022-11-AS-UCOL-CFSW27-20220627165351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 06/09/2022
Date Signed: 06/10/2022 06:20:41 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
06/01/2022 and conducted by Evaluator Susan Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220601152817

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: 52	DATE:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	10:26 AM
MET WITH:	LaDonna D. Worthington		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff are not following doctor's orders for resident

INVESTIGATION FINDINGS:

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On 6/9/22 at 10:26 a.m., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by LaDonna Worthington, LVN. LPA explained to LaDonna Worthington the purpose of the visit. The investigation consisted of the following: LPA conducted interviews on 6/9/22 with (5) staff members, and (5) facility residents. In addition, on 6/9/22, the LPA and Ms. Worthington conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. The LPA also reviewed the following documents provided by La Donna Worthington, LVN, from the Country Villa Terrace Assisted Living Center: LIC 500-Staff Roster, Client Roster, R1’s Physician Report, R1’s Needs Service Plan, R1’s LIC 625 Appraisal Needs Service Plan, R1’s MAR for month May 2022 and June 2022, R1’s Case Notes, and R1’s Medical/ Case Manager Correspondence, House Rules, Resident Medication Staff Instructions, and Procedures for Special Medical Instruction.

Report continued on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220601152817

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: 06/09/2022

NARRATIVE

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Investigation

Allegation: Staff are not following doctor's orders for resident

The investigation revealed, per LPA interviews, with (5) staff members, (5) residents from the Country Villa Terrace Assisted Living Center facility, and also review of facility documents, that the staff did not follow doctor’s orders for facility resident. S1 informed the LPA, that the facility received instructions regarding R1’s medication alterations, for a scheduled medical procedure on 6/2/22. S1 also informed the LPA, that S1 was also made aware by R1, that R1 had received, on the morning of 6/1/22, Eliquis medication, which the facility was instructed, by R1’s Medical Case Manager, not to give to R1, 24 hours prior to R1’s 6/2/22 scheduled medical procedure. In addition, S1 also stated that once, R1 informed S1, regarding the Eliquis intake, then R1’s Case Manager was immediately contacted, so that R1’s 6/2/22 medical procedure may be rescheduled. In addition, as a result of R1’s 6/1/22 morning medication incident, during R1’s 6/1/22 evening medication disbursement, R1 did not receive all of R1’s required evening medications, because S1 states, that the staff, were cautious of give R1's medication, so that R1’s medical procedure, would not be re-scheduled again. The facility corrected R1's evening medication disbursement, and on 6/2/22, R1 received all required evening medication, per R1's Case Manager's instructions. The LPA also interviewed (5) facility staff personnel, and 5 of the 5 staff personnel interviewed, informed the LPA that they follow instructions provided by case managers, and medical professionals. In addition, the LPA interviewed (5) residents, and 4 of 5 residents interviewed, informed the LPA, that the facility staff provide them medication as required by physician orders. Also, the LPA interviewed (5) residents, and 5 of 5 residents interviewed, informed the LPA, that the facility staff assist them with their care needs, and also, 5 of 5 residents interviewed, informed the LPA, that staff are available to them when needed.

On 6/9/22, at 10:45 am, the LPA was informed by S1, that Eliquis was given to R1 on 6/1/22, thereby resulting in R1’s medical procedure to be rescheduled from 6/2/22 to 6/3/22. In addition, S1 informed the LPA, that on 6/1/22, R1 did not receive all required evening medication, because staff were cautious, and did not want R1’s 6/3/22 medical procedure rescheduled again.

Based on information gathered, the LPA did find sufficient evidence to support allegation " Staff are not following doctor's orders for resident. ”

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are 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 was conducted with LaDonna D. Worthington, LVN and a hard copy of the LIC 9099 and LIC 9099D was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20220601152817

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: 06/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/20/2022 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	87464(f)(1)(c)Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision…(c) …Assistance includes assistance with taking medications, money management, or personal care. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will fax to LPA staff procedures for implementing resident medical procedure instructions, and also conduct a Medtech training session, explaining instructions, and provide LPA with a staff Medtech sign-in sheet. In addition, also fax to LPA a signed self-certification statement that the Administrator
	8 9 10 11 12 13 14	Based on interviews, and record review, the licensee failed to ensure that R1's medication was disbensed as required for R1's upcoming medical procedure: On 6/9/22, at 10:45 am, LPA was informed by S1 that R1 received, Eliquis on 6/1/22, thereby requiring R1’s medical procedure to be rescheduled, and also that on 6/1/22, R1 did not receive all required evening medications, which posed a potential health risk to residents in care.	8 9 10 11 12 13 14	read and understands Regulation 87464 Basic Services POC Due Date is 6/20/22 LPA Fax Number (323)981-1781
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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 Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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