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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201010
Report Date: 01/20/2023
Date Signed: 01/21/2023 06:43:56 AM


Document Has Been Signed on 01/21/2023 06:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
198201010
ADMINISTRATOR:ESTELLA LEWISFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 60DATE:
01/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Vladimar KaplunTIME COMPLETED:
04:44 PM
NARRATIVE
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On 01/20/23, Licensing Program Analysts (LPAs) Ernand Dabuet, Lourdes Montoya, Martessa Brown, and Pam Bunker conducted a case management inspection visit at this facility. LPAs met with Vladimar Kaplun and explained the purpose of the visit.

During an initial inspection visit on today's visits. LPAs observed the following deficiencies:

Non-Associated Staff:
Staff #1 - #2 (S1-S2) did not have a signed Criminal Background Clearance Transfer Request in Guardian (LIC 9182).
Smoke Detectors:
Smoke detectors in bedrooms # 201 and 207 are broken.
Fire Extinguishers:
Two fire extinguishers on the 2nd floor and 3rd floor in the hallway are not mounted.
Physical Plant:
The screen door in resident bedroom #214 is not properly working. The carpet is dirty on the stairs between the second floor and third floor, resident bedroom #334, and in the hallway on the second floor.
The bathroom in resident bedroom #211 has no exhaust fan and the bottom wall in the bathroom is scraped out and molded. There are no chairs in resident bedrooms #207, #216, and #218.
Bathrooms:
All bathrooms do not have hand washing posters; there are no skid mats in resident bathrooms # 201, #207, #208, and #220. The toilets not working on the 2nd floor for bathroom #201 were missing a cover and the toilet wasn’t working, #209 water doesn’t turn off and the toilet was not working and #212 toilet was not working. Carpets leading in bedrooms room 333 and 334 were dirty with stains and unsanitary.

Evaluation Report continues LIC 9099-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2023 06:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2023
Section Cited

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87355(c)(1) (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182.
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Licensee to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date 01/21/23 ***A CIVIL PENALTY IS BEING ISSUED TODAY***
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This requirement is not met as evidenced by: Based on (record review), the licensee did not comply with the section cited above. LPA identified (2) staff did not have asociation at this facility. This violation which poses an immediate health, safety or personal rights risk to persons in care.
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A CIVIL PENALTY IS BEING ISSUED TODAY***
Type A
01/21/2023
Section Cited

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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Licensee to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date 01/21/23. Fax correction at 323-981-1781,
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Based on observation, the licensee did not comply with the section cited above. LPAs identified smoke detectors bedrooms #201 & 207 broken. This violation which poses an immediate health, safety or personal rights risk to persons in care.
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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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/20/2023
NARRATIVE
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BEDROOMS:
Room #217 is cluttered.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8,

*IMMEDIATE CIVIL PENALTY*

Deficiencies are issued and an exit interview is conducted with Vladimar Kaplan. A copy of this report, appeal rights, and civil penalty were provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/21/2023 06:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:

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Licensee to ensure to make correction for screen door, dirty carpets, install exhaust fan, bathroom mold wall must be cleared, and fire exthinquishers must be afix properly on wall and covered for resident in care. Proof of correction to CCLD by POC due date 02/03/23. Correction must be fax to 323.981.1781.
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Based on observation, the licensee did not comply with the section cited above. LPAs identified screen door not working, dirty carpets, no exhaust fan, bathroom wall with mold, cluttered rooms,fire extinquishers not mounted/covered for safety,This violation which poses a potential health, safety or personal rights risk to persons in care.
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Type B
02/03/2023
Section Cited

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87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
This requirement is not met as evidenced by:

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Licensee to ensure that all bathrooms must have non-skid mats available for resident in care. Proof of correction to CCLD by POC due date 02/03/23. Correction must be fax to 323.981.1781.
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Based on observation, the licensee did not comply with the section cited above. LPAs identified no non-skid mats for rooms 201, 207, 208, & 220, This violation which poses a potential health, safety or personal rights risk to persons in care.
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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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 01/21/2023 06:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited

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87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large ereside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
(B) Bedroom furniture, which shall include, for each resident, a chair, nightstand, a lamp, or lights sufficient for reading, and a chest of drawers...
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Licensee will ensure for personnel accomations chairs in rooms for 207, 216 and 218 for resident in care. Proof of correction must be sent by POC due dateL 02/03/23 by fax 323-981-1781.
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This requirement is not met as evidenced by: Based on (observation), the licensee did not comply with the section cited above. LPAs identified no chairs in rooms 207, 216 and 218. This violation which poses a potential health, safety or personal rights risk to persons in care.
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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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5