198201010-1-20-2023-11-AS-UCOL-CPFMH7-20230227083702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 01/20/2023
Date Signed: 01/20/2023 09:06:39 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
09/07/2022 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20220907100306

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:	09:00 AM

ALLEGATION(S):

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Illegal Eviction
Facility does not have enough staff to care for residents
Staff did not remove discard foods from resident's room
Staff do not provide activities for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent complaint investigation visit at this facility to deliver complaint investigation findings. LPA met with Vladimir Kaplun, and the purpose of the visit was explained.

The investigation consisted of the following: On 09/15/2022 LPA Antonia Alvizar conducted a tour of the facility. Requested resident roster, staff roster, physical plan and other service documents. LPA Alvizar interviewed Residents (R#1-R#6) and Staff (S#1- S#5). On 01/19/2023 LPA Alvizar conducted a review of the facility Personnel Report.

Report continues LIC9099.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
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-20220907100306

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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Investigations Revealed

Regarding the allegation: “Illegal Eviction”. During interviews conducted on 09/15/2022, it revealed the following, 1 out of 6 residents did not know about the allegation, resident R#2 stated, “Not that I know of, I have not heard it happen and not personally to me”; 5 out of 6 residents disagree with the allegation, resident R#1 stated, "No, I don't think there are any in this place". 0 out of 6 residents agreed the with allegation. 5 out of 5 staff disagree with the allegation, staff S#1 stated, “No, If I have given a resident an eviction is because we cannot meet their medical needs or they have broken house rules”. 0 out of 5 staff agree with the allegation. According to witness, resident needs maximum assistance with transferring from bed to wheelchair, rolling, sitting and standing” Based on interviews, the above allegation is unsubstantiated.

Regarding the allegation: “Facility does not have enough staff to care for residents”. During interviews conducted on 09/15/2022, it revealed the following, 4 out of 6 residents disagree with the allegation, resident R#6 stated, " No, they have a lot of staff " 2 out of 6 residents agreed the allegation, resident R# 2 stated “Yes, this facility does not have enough staff ". 5 out of 5 staff disagree with the allegation, staff S#3 stated, “No, I feel that there is enough staff to care for residents”. 0 out of 5 staff agree with the allegation. Based on interviews the above allegation is unsubstantiated.

Regarding the allegation: “Staff did not remove discard foods from resident's room”. During interviews conducted on 09/15/2022, it revealed the following, 1 out of 6 residents did not know about the allegation, resident R#1 stated, “I would not know anything about that. When I eat, in my room then caregivers usually wait 25 minutes then they come pick up my tray". 5 out of 6 residents disagree with the allegation, resident R# 4 stated, "No, with me they remove it right away". 0 out of 6 residents agreed the allegation. 5 out of 5 staff disagree with the allegation, staff S#2 stated, “No, It's an Assisted Living and personal property cannot be removed from resident's room unless they inform the staff". 0 out of 5 staff agree with the allegation.
Based on interviews, the above allegation is unsubstantiated.

Continued in LIC 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
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-20220907100306

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 the allegation: “Staff do not provide activities for residents”. During interviews conducted on 09/15/2022, it revealed the following, 6 out of 6 residents disagree with the allegation, resident R#1 stated, " Mrs. Sussy provides games, movies, bingo and entertainment plus monthly Birthday parties for residents birthday on their month". 0 out of 6 residents agreed the allegation. 5 out of 5 staff disagree with the allegation, staff S#4 stated, “No, we provide activities for residents there is a Monthly Calendar in every single room. Caregivers help me to call residents for activities”. 0 out of 5 staff agree with the allegation. Based on interviews the above allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.”

Exit interview conducted and a copy of report was provided to Wellness Director Vladimir Kaplun.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
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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