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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 02/09/2023
Date Signed: 03/23/2023 10:33:30 AM

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
02/03/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230203084422
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: 65DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:ADMINISTRATOR VLADMIR KAPLUNTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident physically assaulted another resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Country Villa Terrace Assisted Living Center on 02/09/2023 at around 09:30 AM and was greeted by Administrator (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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 3
Control Number 11-AS-20230203084422
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: 02/09/2023
NARRATIVE
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced 10-day visit on 02/09/2023 approximately around 09:30 AM. LPA Calderon initiated an investigation for the above-mentioned allegation and conducted a face-to-face interview with Administrator (S1). On 02/06/2023 LPA Calderon attempted to interviewed W1 for complaint. On 02/09/2023 LPA Calderon requested copies of the following: Staff and Resident rosters, admission agreement for R2, Needs and Service Plan, Physician Report for R2. On 02/09/2023 LPA Calderon interviewed S1-S3 for complaint. On 02/09/2023 LPA Calderon interviewed R1-R6 for complaint.

Regarding Allegation #1: Resident physically assaulted another resident in care.

On 02/06/2023 LPA Calderon called and emailed W1 for complaint, no response to message left or email sent to W1 for complaint. On 02/09/2023 LPA Calderon interviewed R1 for complaint. R1 states that R1 was laying on R1 bed sleeping when R2 entered R1 room and attacked R1. R1 states that R2 stated that R1 was making too much noise moving furniture. R1 states that R1 had not been moving anything prior to the attack. R1 states that R2 punched R1 leg putting a small scratch on R1 leg. R1 states that roommate witness attack and 2 staff also witness the attack. R1 states that R2 came back the next day with a stick but could not get into R1 room. R1 does not know why R2 attacked R1 while in bed. On 02/09/2023 LPA Calderon interviewed R2 for complaint. R2 states that R2 lives below R1 on the second floor. R2 states that R1 and R1 roommate R3 make noise at all times of the day and night and that on the incident day R1 was moving furniture. R2 states that R2 got into R2 wheelchair and went to the third floor and R2 went to R1 room. R2 states that R1 room door was open and R2 looked inside and R1 started to curse at R2 from the hallway in Spanish. R2 states that R2 got mad at R1 when R1 cursed at R2. R2 states that R2 entered R1 room. R2 states that R1 started to kick R2 and then R2 punched R1 in the leg. R2 states that R2 did not attack R1 first until R1 started to kick R2. R2 states that R2 has complained about R1 making noise day and night and staff has done nothing. On 02/09/2023 LPA Calderon interviewed R3 for complaint. R3 states that R3 is roommates with R1 and did not see R2 attack R1 or see R2 inside R1 and R3 room. R3 has no idea what R1 is stating and has no knowledge of R2 attacking R1 while in bed. On 02/09/2023 LPA Calderon interviewed R4-R6 for complaint.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20230203084422
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: 02/09/2023
NARRATIVE
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 Residents have no knowledge of any attack by R2 on R1 but did hear about the supposed attack that happened. On 02/09/2023 LPA Calderon interviewed S1 for complaint. S1 states that case worker informed S1 of R2 attacking R1 in R1 room. S1 states that R2 has no history of being aggressive with staff or other residents prior to the incident. S1 states that S1 understands that R2 entered R1 room, and a fight started. S1 does not know who started the fight but does acknowledge that R2 did not have permission to enter R1 room and no fight would have started if R2 had not gone into R1 room. On 02/09/2023 LPA Calderon interviewed S2-S3 for complaint. S2 states that S2 does not know of any fight between R1 and R2. S3 states that S3 was called to help with an incident that happened in R1 room. S3 states that S3 does not know who started the fight but S3 did see R2 pulling at R1 legs trying to pull R1 off R1 bed and did see R1 kicking at R2 direction. S3 called the police but the police did not come to the scene. S3 states that S3 did not see any resident punch the other resident. On 02/09/2023 LPA Calderon reviewed R2 facility file, R2 does not suffer from mental health issues or have anger issues. On 02/09/2023 LPA Calderon reviewed facility house rules, appears R2 may be in violation of rules 1,3,5,6 and 9

Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator (S1).

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3