198201010-1-20-2023-11-AS-MVAO-CNNSMM-20230202130008

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 01/20/2023
Date Signed: 01/20/2023 09:11:11 AM

Unsubstantiated

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
05/26/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220526153634

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: 60	DATE:	01/20/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Vladimir Kaplun		TIME COMPLETED:	09:17 AM

ALLEGATION(S):

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Resident is selling illegal drugs on facility premises.
Residents are using illegal drugs on facility premises.
Facility is not following COVID-19 isolation and/or quarantine guidance.
Resident was not accorded dignity in relationships with staff.

INVESTIGATION FINDINGS:

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On 01/20/23, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Wellness Director Vladimir Kaplun. LPA conducted a risk assessment prior to entering facility. Kaplun informed LPA that the facility has no COVID cases nor do any of the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit and deliver the findings pertaining to the above-mentioned allegation(s).

An initial 10-Day visit was conducted by LPA Don Senaha on 05/27/22 with Administrator (Clarizze Punit). During this visit, LPA Senaha conducted a physical tour of the facility for health and safety purposes. LPA Senaha obtained copies of service documents: Admissions Agreement, Emergency I.D. & Information, Physician’s Report, Appraisal/Needs and Services Plan, and House Rules for residents; including Facility Staff Roster & Work Schedule, Residents’ Roster, COVID Incident Report (dated 05/26/22), and Facility Staff Training Records.
Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220526153634

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: 01/20/2023

NARRATIVE

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A separate investigation was conducted by the Department of Social Services Investigator (Lorraine Patterson) which included a review of police records and interviews with facility staff and residents.

INVESTIGATION REVEALED THE FOLLOWING:

Regarding Allegation #1: This investigation revealed that a review of local police department records and the facility’s file; a tour of the facility’s physical plant – including Resident #5 ’s bedroom and observation of the facility patio; interviews conducted with anonymous reporting party, facility administrator, housekeeping staff, and residents in care corroborated that they have not observed or witnessed Resident #5 selling illegal drugs (crystal methamphetamine and marijuana) on the facility premises.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Resident is selling illegal drugs on facility premises is found to be UNSUBSTANTIATED.

Regarding Allegation #2: This investigation revealed based on interviews conducted with facility staff that they have not witnessed residents using illegal drugs at the facility. Residents in care, corroborated that there’s no confirmation that residents are using illegal drugs at the facility and have not witnessed residents using them. Local police department had no police reports to corroborate the above-mentioned allegation. Facility was not observed to be in an unsafe environment. There’s no evidence in which would threaten the physical health, mental health, safety or welfare of the residents in care.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of LACK OF SUPERVISION: Residents are using illegal drugs on facility premises is found to be UNSUBSTANTIATED.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220526153634

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: 01/20/2023

NARRATIVE

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Regarding Allegation #3: This investigation revealed that residents in care where all separated from each other depending on their test results and/or symptoms following a COVID diagnosis; and, the facility would follow the isolation and/or quarantine guidance. “Positive” residents and “Negative” residents were not to co-mingle; and, the facility had rooms designated for the “Positive” residents and “Negative” residents. The facility had sufficient PPE's for their staff at all times. Facility staff were donning their full PPE's with “COVID Positive” residents in care. When staff would work with “COVID Negative” residents, they always wore their masks and washed their hands – including when they were un-donning their full PPEs. Residents (R1 – R5); generally, stated that they did not observe confirmed COVID residents in care out of their rooms walking throughout the facility; and, the facility does follow the COVID protocol. The facility’s “Mitigation Plan” is also put in place to address an epidemic outbreak and/or communicable diseases specific to COVID. A review of the facility’s profile documented that the facility has been notifying Community Care Licensing and the Department of Public Health regarding their COVID reports.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of OTHER: Facility is not following COVID-19 isolation and/or quarantine guidance is found to be UNSUBSTANTIATED.

Regarding Allegation #4: This investigation revealed that interviews conducted of residents in care (R1 – R5) got along with facility staff and did feel that they were accorded with dignity and respect in their relationships with them. Interviews conducted with facility staff corroborated that they had not received a complaint from residents that they felt as though they were not being accorded with dignity from a specific staff member. A review of the facility staff records on the topic of “Personal Rights” training was conducted.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Resident was not accorded dignity in relationships with staff is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Wellness Director Vladimir Kaplun.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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