198201010-7-18-2022-11-AS-JHAD-CGPNWE-20220726104922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 07/14/2022
Date Signed: 07/18/2022 01:52:42 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
07/11/2022 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20220711135005

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:	10:00 AM
MET WITH:	ADMINISTRATOR MELISSA CHRISTOPHER		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Roaches in resident's bedroom.
Facility in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility on 07/14/2022 at 10:00 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10 day visit on 07/14/2022 approximately 10:00 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 07/14/2022 LPA Calderon requested copies of the following: staff and residents’ roster, SIR reports (for current complaint), cleaning records for R1 room, cleaning reports for facility, maintained records and pest control reports for 3 months. On 07/14/2022 LPA Calderon reviewed facility records for complaint. On 07/14/2022 LPA Calderon interviewed S2 – S5 for complaint and on 07/14/2022 LPA Calderon attempted to interviewed R2 – R5 for complaint. On 07/12/2022 LPA Calderon interviewed W1 for complaint. On 07/18/2022 LPA Calderon walked outside of building with R1 to inspect hold in facility wall.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
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 3

Control Number 11-AS-20220711135005

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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Regarding Allegation #1: Roaches in resident bedroom.

On 07/12/2022 LPA Calderon interviewed W1 who states that there are roaches in R1 room and that R1 has complained to staff and staff has not addressed R1 concerns. On 07/14/2022 LPA Calderon interviewed S1 – S5 all state that there has been a major roach problem in the past and that R1 room does have roaches which they have not addressed. On 07/14/2022 LPA Calderon interviewed R2-R5 who state that in the past there has been major roach problems, but some minor roach issues that pest control sprays for. On 07/14/2022 LPA Calderon toured the facility and R1 room. LPA Calderon noted roaches in R1 dresser area but did not see or find any roaches in the facility. On 07/14/2022 LPA Calderon reviewed pest control records for two prior months and the reason for pest control coming to the facility was roaches.

Regarding Allegation #2: Facility in disrepair.

On 07/14/2022 LPA Calderon toured the facility with administrator and LPA Brown. LPA Calderon walked outside with R1 to the side alley near the facility. LPA Calderon noted 2 large vent pipes with vent hot air away from the building. The vent has a broken grate that can allow roaches and other larger animals into the building . Staff was not able to produce any maintained records or cleaning records for LPA to review and S1 stated that the staff had not followed S1 instruction regarding cleaning and documentation records.

Based on LPA observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) “Roaches in residents’ bedroom” “Facility in disrepair” is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted and copy of the Complaint Report was provided to the Administrator.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
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: 3 of 3

Control Number 11-AS-20220711135005

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 07/22/2022 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	80087 Buildings and Grounds: The facility shall be clean, safe, sanitary and in good repair at all times:1:The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to provided pest control records and cleaning records for facility that addresses the roach problem by 07/22/2022
	8 9 10 11 12 13 14	Based on interviews, observations and records the licensee failed to ensure that the facility is cleaned and maintained. Staff did not keep facility clean, trash was found, roaches were found in R1 room.This poses a potential health & safety risk to residents in care.	8 9 10 11 12 13 14
Type B 09/16/2022 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087 Buildings and Grounds(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	eCorporate to repair vent in wall to prevent any bugs from entry into the building. Administrator to send LPA proof of replacement of vemt grate by POC due date.
	8 9 10 11 12 13 14	Based on interviews, observations and records the licensee failed to ensure that the facility is cleaned and maintained. Staff did not inspect building and repair hole in facility wall.. This poses a potential health & safety risk to residents 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: Jose Calderon	TELEPHONE: (323) 213-1153
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)

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