198201010-2-13-2023-11-AS-SCIS-CSTTAZ-20230615143423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 01/20/2023
Date Signed: 02/13/2023 04:24:41 PM

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
07/07/2022 and conducted by Evaluator Pamela Bunker

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220707163751

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:	08:45 AM
MET WITH:	Vladimir Kaplun		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not meeting resident's dietary needs
Resident loss a substantial amount of weight
Staff are not providing resident with toiletries
Staff are not providing adequate food service for residents
Staff are not providing resident money
Staff are mismanaging residents medication

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Friday, January 20, 2023. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Wellness Director Vladimir Kaplun. LPA Bunker explained the purpose of today's visit.

The investigation consisted of the following: On 07/13/2022, LPA Bunker met with Administrator Melissa Christopher. During the course of the complaint investigations on 07/13/2022 and 01/20/2023, interviews were conducted with staff 1-4 (S1-S4) and residents 1-6 (R1-R6). LPA Bunker asked questions relevant to the nature of the complaint. S1-S4 and R1-R6 stated staff is meeting the resident's dietary needs, the resident has not lost a substantial amount of weight, residents purchase their own toiletries, and there is a fee if the facility provides toiletries. The facility has travels size backup toiletries for the residents that can't afford toiletries. Staff is providing residents with adequate food service. Staff is providing the resident with their P & I money. The staff is not mismanaging the resident's medication. See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
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 3

Control Number 11-AS-20220707163751

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued LIC9099-C page 2

Allegation #1: Staff are not meeting resident's dietary needs
S1-S4 and R1-R6 stated staff is meeting the resident's dietary needs and denied the allegation.

Allegation #2 Resident lost a substantial amount of weight
S1-S4 and R1-R6 stated none of the residents lost a substantial amount of weight and denied the allegation.

Allegation #3 Staff are not providing the resident with toiletries
S1-S4 and R1-R6 stated residents purchase their own toiletries, and there is a fee if the facility provides toiletries. The facility does have emergency travel-size toiletries for those who can't afford personal hygiene items. S1-S4 and R1-R6 denied the allegation.

Allegation #4 Staff are not providing adequate food service for residents
S1-S4 and R1-R6 stated staff is providing residents with adequate food service. S1-S4 and R1-R6 stated that residents are served three (3) meals per day plus snacks and denied the allegation.

Allegation #5 Staff are not providing residents money
S1-S4 and R1-R6 stated staff is providing the resident with their P & I money and denied the allegation.

Allegation #6 Staff are mismanaging resident's medication
S1-S4 and R1-R6 stated staff is not mismanaging the resident's medication. S1-S4 and R1-R6 stated that once ordered by the physician the medication is given to the residents according to the physician's directions. S1-S4 and R1-R6 denied the allegation.

See continued LIC9099-C page 3

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
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 3

Control Number 11-AS-20220707163751

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued LIC812-C page 3

Investigation revealed the following: Staff 1-4 (S1-S4), and residents 1-6 (R1-R6), stated staff is meeting the resident's dietary needs. S1-S4 stated that modified diets prescribed by a resident's physician are being provided. S1-S4 stated resident has not lost a substantial amount of weight, he did not lose 100 lbs. S1-S4 stated residents purchase their own toiletries, and there is a fee if the facility provides toiletries. However, the facility has emergency travels size backup toiletries for those residents that can't afford toiletries. Staff stated they are providing residents with adequate food service. S1-S4 and R1-R6 stated residents are served three (3) meals per day plus snacks and modified diets prescribed by a resident's physician is being provided. We observed nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. S1-S4 and R1-R6 stated the facility staff does not provide residents with money. If the facility is the residents' direct payee leftover funds after room and board are paid the reminding balance is deposited and a trust account for residents and they can request money at any time through their P & I waiver program. S1-S4 and R1-R6 stated staff is not mismanaging the resident's medication. S1-S4 stated that once ordered by the physician the medication is given according to the physician's directions. Medications were observed and Med Techs are dispensing medication according to the doctor's orders. S1-S4 and R1-R6 denied the allegations.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099 and LIC9099-Cs was provided to the facility Wellness Director Vladimir Kaplun

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
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: 3 of 3