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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201010
Report Date: 11/18/2022
Date Signed: 11/18/2022 04:42:54 PM


Document Has Been Signed on 11/18/2022 04:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
198201010
ADMINISTRATOR:ESTELLA LEWISFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 62DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ladonna Worthington, LVNTIME COMPLETED:
04:45 PM
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On 11/18/2021 at 12:30pm, Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Alvizar conducted a risk assessment via -phone with Administrator Melissa Christopher. Based on the assessment, the facility has 4(four) residents that tested Positive Covid-19 infection this week. LPA verified that the facility submitted a mitigation plan report.

At the facility LPA met with LaDonna Worthington, LVN and Neil Valdenarro, MedTech. LPA Alvizar and LaDonna toured the facility. LPA was properly screened for Covid-19 symptoms LPA was properly equipped with Fit tested N-95 and gloves.

During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility garage entrance; visitors log, PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored onsite in a locked cabinet. Resident rooms with Positive COVID -19 case had labeled carts with gloves, goggles, masks, gowns, shoe covers and contact precaution signs on the door.

Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the dining room/ activity room. LPA observed staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility.

Continue on LIC 809c

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/18/2022
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The facility does not support residents with memory care unit. Rooms #201, #209 and #215 was inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Furniture in common areas are clean, in good repair and also socially distanced.

There are no weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly and shower’s grab bars were secure. The water temperature measured between 105.4 and 108.7 degrees Fahrenheit in residents’ room and within regulation in the common area. A comfortable temperature was maintained in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept locked and separate. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to resident in care. The First Aid kit was available and inaccessible to residents. Several fire extinguishers were observed throughout the facility.

Outside, indoor patio ground were toured, and no bodies of water were observed. Walkways around the facility were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

During visit LPA observed the following Advisory- Technical Assistance.


An exit interview was conducted, and a copy of this report was provided to LVN, LaDonna Worthington.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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