198201010-7-14-2022-11-AS-UCOL-CGSW24-20220729165343

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:19:49 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
07/07/2022 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220707141139

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: 50	DATE:	07/14/2022
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Sonia Johnson-Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff refused to provide resident with a copy of admissions agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst’s (LPA’s) Martessa Brown and Jose Calderon an unannounced initial 10-day complaint visit to investigate the above allegations. LPA's was met by Sonia Johnson, Director and Melissa Christopher, Assistant Administrator and the purpose of the visit was explained.

Investigation consisted of the following: On 7/14/22, LPA toured the facility physical plan, conducted interviews with administrators, director and residents #1-#5 (R1-R5), obtained R1’s file, resident/staff roster and requested incident reports.

The investigation revealed the following:

Allegation: Staff refused to provide resident with a copy of admissions agreement

On 7/14/22, LPA interview the Administrator Clarrize Punit regarding the above allegation. She stated R1 family member requested R1’s admissions agreement, last month.
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: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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 5

Control Number 11-AS-20220707141139

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: 07/14/2022

NARRATIVE

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She stated they have been looking for the file and couldn’t find it. She stated emailed the family member to inform they are still looking for file. Interviews conducted with Assistant Administrator- Christopher and Director Johnson, both stated they couldn’t fine R1’s file and have been looking. Both stated the clients file must have been misplaced. She stated they will need to create a new file for R1. On 7/14/22, Later on during the visit LPA was provided R1's file. LPA reviewed R1 File and the Admissions agreement was not current and residents records was missing files. Based on interviews and records 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: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20220707141139

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: 07/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/21/2022 Section Cited CCR 87506(a)(b)	1 2 3 4 5 6 7	87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.(b) Each resident’s record shall contain at least the following...This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide R1 a copy of their admissions agreement and update admission agreement and records. Administraor will read reagulation to ensure residents records are up to date and send proof by POC due date.
	8 9 10 11 12 13 14	Based on observation and interviews conducted, Administrator could not find R1's records to provide them an admissions agreement. LPA reviewed R1's records and was missing information such as emergency contact, physicians report and updated admissions agreement. This is a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
07/07/2022 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220707141139

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: 50	DATE:	07/14/2022
		UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Sonia Johnson-Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide resident a 30day notice to change rooms.
Staff did not safeguard resident's personal items

INVESTIGATION FINDINGS:

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Unsubstantiated

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: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20220707141139

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: 07/14/2022

NARRATIVE

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Staff did not provide resident a 30-day notice to change rooms

On 7/14/22, LPA interview the Administrator regarding the above allegation. Administrator stated R1 was having a problem with resident below. Resident stated R1 was banging on the walls at night. Administrator started resident did not want to change rooms but R1 agreed to move to another bedroom. She stated incident took place last month. Interview conducted with Director and Assistant Administrator, both stated the protocol for a bedroom change is to notify the resident, so they can have enough time to gather their belongings. Based on interviews the above allegation is unsubstantiated.

Staff did not safeguard resident's personal items.

On 7/14/22, LPA interview Administrator she stated resident went from a single bedroom to a shared occupancy bedroom. She stated R1’s belongings were moved the new bedroom. She stated the large items had to remain in the resident’s prior bedroom for storage until resident can find smaller shelving. She stated R1 will need to purchase smaller shelving to move computers and books. Interview conducted with Assistant administrator and Director stated resident belongs are secure and lock and they also have an inventor sheet for residents belongs. Both stated when a resident moves their belongings are packed up and inventory is documented. Interview R1, stated belongings were moved but the computer and desk are still in the old bedroom. Interviewed R2-R4 they stated do not have a problem with staff safeguarding their personal belongings. Based on interviews the above allegation is unsubstantiated.

Although the allegation is valid or may have happened there is insufficient evidence to support the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5