198201010-7-22-2022-11-AS-UCOL-CLDNM4-20221121093429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 07/22/2022
Date Signed: 07/22/2022 04:44:59 PM

Unsubstantiated

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
07/18/2022 and conducted by Evaluator Antonia Alvizar

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220718172625

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: 56	DATE:	07/22/2022
		UNANNOUNCED	TIME BEGAN:	08:26 AM
MET WITH:	Melissa Christopher,Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff retaliating against resident.

INVESTIGATION FINDINGS:

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On 07/22/2022 Licensing Program Analyst (LPA) Antonia Alvizar conducted a unannounced complaint visit to the investigate the above allegation. LPA Alvizar met with Administrator Melissa Christopher and explained the purpose of this visit.

The investigation consisted of the following: On 7/22/2022 LPA toured the facility physical plan, conducted interviews with administrator, and residents #1-#9 (R1-R9), obtained R#1 File, Admission Agreement, Incident Reports , resident and staff roster.

Report continues LIC9099.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

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-20220718172625

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: 07/22/2022

NARRATIVE

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Regarding the allegation: “Staff retaliating against resident.” On 07/22/2022 during interviews conducted, 2 out of 9 residents did not provide an answer. 6 out of 9 residents denied the allegation, resident R# 8 stated,"No, I have never seeing that. Staff are very cooperative with everyone and try to do the best they can". 1 out of 9 residents agreed the allegation, resident R#1 stated “No, I have not seen staff doing retaliation against resident. In my case I believe former administrator is doing this allegation for a complaint i file with Community Care Licensing Department" but did not elaborate.

On 7/22/2022 former Administrator Clarizze Punit stated, "We don't tolerate any form of abuse including retaliation".

On 07/22/2022 Administrator Melissa Christopher stated “We are trying to accommodate all resident’s I have zero knowledge of my staff retaliating against residents we have a zero policy of retaliation”.

Regarding the allegation: “Staff retaliating against resident.” Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.”

Exit interview conducted with Administrator Melissa Christopher and a copy of report was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC9099 (FAS) - (06/04)

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