198201010-10-21-2020-11-AS-JHAD-BVG3JD-20201117171723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 10/20/2020
Date Signed: 10/21/2020 10:22:21 AM

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
08/13/2020 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200813084631

FACILITY NAME:	COUNTRY VILLA TERRACE ASSISTED LIVING CENTER		FACILITY NUMBER:	198201010
ADMINISTRATOR:	PADAMA, ANTHONY		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS: 64	DATE:	10/20/2020
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Sherrina Lewis, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident is not provided a comfortable room temperature
Resident is not provided a copy of the facility's Admission Agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Sherrina Lewis, the facility administrator.

Based on the LPA's investigation, the investigation revealed the following. For Allegation #1 – Resident is not provided a comfortable room temperature. On 08/18/20 @ around 3:30pm, LPA Soto interviewed Ray Cortez, Maintenance worker. He stated that the thermostat that controls the room temperature for R#1 room is in another resident room, room #315. That thermostat controls 4 rooms including R#1’s room. LPA Soto virtually saw the thermostat that controls R#1’s room temperature, and it was set at 71 degrees. LPA Soto asked facility to provide R#1 with a portable fan, R#1 was given a portable fan by the facility. R#1, also stated that, the room’s temperature is cool and comfortable.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 11-AS-20200813084631

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: 10/20/2020

NARRATIVE

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On 09/03/20, @ around 2:00PM, LPA Soto interviewed R#2 – R#6, They stated that their room temperatures are at a comfortable temperature. They do not have a problem with their air conditioners.

For Allegation #2 – Resident is not provided a copy of the facilities Admission Agreement. On 08/18/20, at around 3:10pm, LPA Soto interviewed Administrator, she stated that she had provided a copy of the original Admission Agreement to R#1. She also provided a copy of R#1 original Admission Agreement to LPA Soto. On 09/02/20 at around 2:00pm, R#1 confirmed that the Administrator had given R#1 a copy of the R#1 original Admission Agreement.

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

telephonic exit interview was conducted with Sherrina Lewis, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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
08/13/2020 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20200813084631

FACILITY NAME:	COUNTRY VILLA TERRACE ASSISTED LIVING CENTER		FACILITY NUMBER:	198201010
ADMINISTRATOR:	PADAMA, ANTHONY		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS: 64	DATE:	10/20/2020
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Sherrina Lewis, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility is not abiding by the Admission Agreement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Sherrina Lewis, the facility administrator.

Based on the LPA's investigation, the investigation revealed the following. For Allegation #3 – Facility is not abiding by the Admission Agreement. On 09/02/20, R#1 stated that the facility was not providing transportation to residents for medical and/or dental appointments, because they laid off the driver. R#1 had to take Access or Uber and pay with R#1 own money. Administrator was interviewed on 09/03/20 at around 2:00pm by LPA Soto, she stated that they laid off driver because of Covid-19 pandemic. Most of the residents were making virtual appointments and had no need for a driver. She also stated that they might hire the driver back after the pandemic is over. R#1 should not be paying for Uber with their own money, that is a Basic Service and it's included in the monthly payment. The facility should be providing payment for Uber or

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20200813084631

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/30/2020 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This was not met as evident by facility not providng transportation for resident as admission agreement states and not paying for transportation by facility.	1 2 3 4 5 6 7	Facility will pay for all Public transportation for all residents that have that in their admission agreements by POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20200813084631

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: 10/20/2020

NARRATIVE

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any public transportation for all the residents using those services and it's specifically in their Admission Agreements.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

A telephonic exit interview was conducted with Sherrina Lewis, Administrator and a hard copy was provided via email for signature and Appeal Rights provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 5