198201010-2-2-2023-11-AS-EMAZ-CRJTCC-20230505143630

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 01/20/2023
Date Signed: 02/02/2023 11:17:05 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
06/14/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210614141546

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:	09:10 AM
MET WITH:	Valdimir Kaplun		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Residents have access to illegal drugs in the facility
Resident was sexually abused by another resident
Facility staff did not prevent resident from being bullied by other residents
Facility staff are not dispensing medications as prescribed

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 withValdimir Kaplun , the facilities Administrator and the purpose of the visit was explained.

The investigation consisted of the following: on 6/15/21, Investigator Tiffany Brunelle accepted an assignment to investigate the following allegations: Residents have access to illegal drugs in the facility and Resident was sexually abused by another resident. On 6/17/21, Interview was conducted with resident R1. On 6/15/21 LPA Brown conducted a 24 hour visit and toured the facility. Interviews was conducted with Residents R1-R6 and staff S1-S7.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (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 5

Control Number 11-AS-20210614141546

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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Residents have access to illegal drugs in the facility

It was alleged that residents are passing illegal drugs in the facility with the help of staff members. On 6/16/21, interview was conducted by investigator regarding allegation and R1 did not inform of any illegal drug activity. LPA conducted interviews with R1, stated believes drugs such as crystal method is being used on the patio, but has not witness. Interviews conducted with R2-R6, stated they have not seen witnesses any illegal drug activity in the facility. LPA conducted interviews with S1-S7, staff stated they have not seen any resident’s with illegal drugs in the facility and have not heard. There is no evidence of illegal drugs being used at the facility.

Resident was sexually abused by another resident

It was alleged that resident was groped by a female. on 6/16/21, interview was conducted by investigator regarding allegation and R1 did not mentioned any type of sexual abuse by another resident. Interviews conducted with R2-R6, stated they have not witnessed any resident being sexually abuse and they have not been sexual abused by any resident. LPA conducted interviews with S1-S7, staff stated they have not heard or witness any resident being sexually abused. here is no evidence of sexual abuse.

Facility staff did not prevent resident from being bullied by other residents

I was alleged that staff is not preventing residents from being bullied by other residents. During interviews 1 out of 6 residents stated heard a resident threaten people. All 7 staff stated they have not witness or heard of any residents being bullied.

Facility staff are not dispensing medications as prescribed

It was alleged that residents had frequent errors in medication management. Interviews conducted and 2 out of 6 residents stated facility had run out of medications. LPA asked administrator for 2 resident mars records for 2021 and administrator was unable to locate. Interviews conducted and 2 out of 7 staff stated they use to have problems with resident’s medication. LPA was unable to determine if medication was mismanage.

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

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (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 5

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
06/14/2021 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210614141546

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:	09:10 AM
MET WITH:	Valdimir Kaplun		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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9

Allegation: Facility has roaches

INVESTIGATION FINDINGS:

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13

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 withValdimir Kaplun , the facilities Administrator and the purpose of the visit was explained.

The investigation consisted of the following: on 6/15/21, LPA conducted visit to the above facility and toured the facility physical plant. Investigator Tiffany Brunelle accepted an assignment to investigate the following allegations: . Interviews was conducted with Residents R1-R6 and staff S1-S7.

The investigation revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (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: 3 of 5

Control Number 11-AS-20210614141546

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 has roaches

It was alleged that the facility has a roach problem not being taken care of. During LPA’s visit on 6/15/21, there was roaches in bedroom 315A. LPA interviewed R1-R6, all residents stated have seen roaches in the facility. On 12/22/22, LPA spoke to R1, R2, R3 and R5 stated they stated facility still has roaches. Interviews conducted and 6 out of 7 staff stated facility has roaches. Staff also stated pest control comes once a month. LPA requested pest control invoices for 3 months was provided 5/10/21 no pest activity and 6/7/21 indicated facility had roaches. Based on interviews and documents above allegation is substantiated.

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 Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (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: 4 of 5

Control Number 11-AS-20210614141546

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)	1 2 3 4 5 6 7	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 evidence by:	1 2 3 4 5 6 7	Licensee will review regulation and will provide a plan on how to keep the facility free from roaches.
	8 9 10 11 12 13 14	Based on observation, documentation and interviews. LPA observed roaches in the facility, staff and residents stated facility had roaches. Pest Control invoices stated facility had roaches. Most recent interviews with staff and residence facility still has roaches. This is a potential risk to residents in care.	8 9 10 11 12 13 14
	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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (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: 5 of 5