198201010-8-2-2022-11-AS-EMAZ-CHW4AX-20220902185640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 08/02/2022
Date Signed: 08/02/2022 07:28:22 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
07/28/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220728155837

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: 58	DATE:	08/02/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Melissa Christopher		TIME COMPLETED:	04:59 PM

ALLEGATION(S):

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The facility is not clean.

INVESTIGATION FINDINGS:

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On 08/02/22 Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial an unannounced complaint visit at this facility. LPA Dabuet was greeted by administrator Melissa Christopher. LPA Dabuet explained the purpose of today's visit.

The investigation included the following; A review of the Resident roster, Staff roster, Face sheets, ID/Emergency, Medication Administration Records, and other pertinent documents associated with resident #1 (R1). Interviews were conducted with residents #1- #5 (R1-R5) and witnesses #1 (W1). A tour of the facility was conducted as well.

Evaluation Report continues on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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-20220728155837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 08/02/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: The facility is not clean.
The details for the complaint states resident #1 (R1) did not want to return to the facility due to the place being dirty. The complainant states that (R1) was admitted to Cedars Sinai Hospital and did not want to return to this facility after his treatment at the hospital. The complaint reports (R1) has been a resident since 2014 and no longer likes the living condition at his group home. An interview with newly appointed administrator (S1) states she was hired on 07/18/22 and is familiar with (R1) claims. (S1) states that (R1) had lived in the same in room #321 since 09/01/14 and was recently relocated in room #324 in May 2022. According to (S1) the facility is going through a major renovation and had completed some of the repairs, cleaning, and rebuilding throughout the entire facility. The renovation is taking place in phases with two rooms at a time. (R1)’s room was up for replacing the carpet with linoleum flooring. (S1) states that ( R1) was notified of the upgrades and agreed with the move to his new shared room #324. (S1) assumes this is when (R1) started being unsatisfied with the facility after he agreed to move. An interview with (R1) states he is no longer a resident effective 07/25/22 and currently resides at a nearby hotel. (R1) claims he did not want to return as the facility is filthy and it reeked with a pungent smell of urine. (R1) unable to provide dates and times of observations. (R1) claims he never brought the matter to discuss with management. Interview with witness #1 (W1) power of attorney to (R1) reports she was informed about the facility's uncleanness condition by (R1). However, she has never been at the facility in-person to observe these conditions. An interview with staff #2 (S2) claims she is responsible for cleaning the entire floor where (R1)'s rooms #321 and #324. (S2) states the rooms are cleaned and sanitized daily and felt the facility is being more diligent with cleaning the facility due to COVID requirements. Interviews with residents #2-#5 (R2-R5) expressed they are content with the cleanliness of their own rooms and felt the facility is a clean and healthy environment.

The Department conducted an inspection of the entire facility and observed carpeting in high-traffic areas were stained and unsanitary in both second and third floors. (S1) reports the facility has a plan and it is in the progress stages to have the interiors carpets deep cleaned. During the inspection, the Department did not identify any malodorous odor emitting throughout the entire facility as mentioned by resident.

Evaluation Report continues on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220728155837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 08/02/2022

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Based on the Department's observation and interviews, records reviewed, the preponderance of evidence standard has been met, therefore the allegation of "The Facility is not clean" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20220728155837

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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: 08/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/02/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... Maintenance shall include provision ...procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee will adhere to Title 22 87303 and create a plan to ensure that the facility shall remain clean, safe and sanitary at all times. The licensee with need to deep/steam clean of carpets. Plan of correction will be submitted by POC due date: 09/02/22.
	8 9 10 11 12 13 14	Based on interviews, observations and records reviews and photographs, the licensee failed to ensure the facility has cleaned carpets in all the high traffic areas in the facility at all times. This poses a potential health & 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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

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