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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 01/20/2023
Date Signed: 02/03/2023 02:28:43 PM

Substantiated


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
08/19/2021 and conducted by Evaluator Martessa Brown
COMPLAINT CONTROL NUMBER: 11-AS-20210819082543
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
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Valdimir KaplunTIME COMPLETED:
09:52 AM
ALLEGATION(S):
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Facility toilet(s) are not maintained in operating condition.
Resident's bed rail(s) are not maintained in operating condition.
Facility carpets are not kept clean.
INVESTIGATION FINDINGS:
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On 1/20/23, Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint visit in order to render investigation findings. During today’s visit LPA met with Valdimir Kaplun, the facilities Administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 8/19/21 LPA Brown toured the physical plant and obtained Resident, staff roster and residents #1-3 file. On 4/28/22, LPA conducted interviews with 1-6 residents, staff members and administrator.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
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)
Page: 1 of 4
Control Number 11-AS-20210819082543
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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Facility toilet(s) are not maintained in operating condition.

On 4/28/22, Interview, conducted with the administrator. She admitted to the toilets not working properly due to broken hinges toilet was not flushing properly. She stated maintenance was aware the situation and she was going to contact plumbing. Interviews with staff members #1-4 stated some of the toilets have not been working for a while. Interviews with residents #1-6 and 4 residents stated their toilets were not working and overflows in bedrooms #206, 207, 209 and 234. LPA verified in 4 of the resident bedrooms and toilets were not flushing or overflowing.

Resident's bed rail(s) are not maintained in operating condition.

It was alleged that the facility bed rails are broken. On 4/28/22, Interview conducted with the administrator stated there was only aware of 1 resident bedrail not operating. She stated maintenance will handle repairs for bed rails. LPA asked for written authorization for bed rails and administrator, stated did not know. During interviews conducted LPA observed 3 out of 6 residence with bed rails not operating in rooms 211a, 212b and 234b, 3 residents stated bed rails have not been working for a while. LPA did not observe in residents file any written orders for bed rails.

Regarding allegation: Facility carpets are not kept clean.

It was alleged that carpets are dirty and haven’t been clean in months. Interviews conducted and 2 out of 4 staff stated carpet need to be clean. Staff stated facility is planning on removing carpets out of room. LPA observed 3 out of 6 residents’ bedrooms in #234b, 205 and 207 were not clean.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview conducted and a copy of the report was given to Vladimir Kaplun

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
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)
Page: 2 of 4
Control Number 11-AS-20210819082543
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
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
CCR
87303(a)
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Type 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 was not met as evident by:
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Licensee will make sure residents bathrooms are working and in good condition in the following rooms #206, 207, 209 and 234 by POC due date.
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LPA observed 4 residentsr toilets were not working and overflows in bedrooms #206, 207, 209 and 234.
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Type B
02/03/2023
Section Cited
CCR
87303(a)
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Type 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 was not met as evident by:
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Licensee will come up with a plan on how they will ensure resident carpets will be cleaned and maintain the cleaning of carpet by POC due date.
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Based on observation and interviews conducted, Licensee did not ensure carpets were clean in residents’ bedrooms #234b, 205 and 207. This a potential health and safety risk to clients in care.

This is a potential health and safety risk to residents 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20210819082543
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
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
CCR
87608(a)(3)
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87608 Postural Supports(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that a...(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

This requirement was not met as evident by
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POC Administrator will obtain a doctor's order for the residents who are using half bed rails or removed bed rails and will repair nonoperating ones by POC due date
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During the tour LPA observed 3 residents in rooms 211a, 212b and 234b half bed rails that were not operating. LPA did not see a physician orders for bed rails.


This is a potential health and safety risk to residents 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
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
LIC9099 (FAS) - (06/04)
Page: 4 of 4