198201010-5-10-2023-11-AS-JHAD-CSTVRQ-20230615164020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 05/10/2023
Date Signed: 05/10/2023 02:50:58 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
02/27/2023 and conducted by Evaluator Jeremiah Randle

COMPLAINT CONTROL NUMBER: 11-AS-20230227115504

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: 68	DATE:	05/10/2023
		UNANNOUNCED	TIME BEGAN:	01:24 PM
MET WITH:	Aaron Mayes Facility Business Office Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not providing resident with a refund
Staff are not administering residents medication in a timely manner

INVESTIGATION FINDINGS:

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On 5/10/2023 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced subsequent complaint visit at the facility listed above. LPA arrived at facility and was greeted by Aaron Mayes Facility Business Office Director for the facility . LPA explained the purposed of the visit is to deliver findings on the allegations listed above.

The investigation consisted of the following:
LPA observed facility, as well as common areas of the facility. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair, LPA reviewed pertinent documents pertaining to the investigation. The following documents were gathered: Staff and Client Rosters, file for resident (R1) and any other pertinent documentation needs and service, physician report, residency agreement, medication records for R1. On 03/07/2023 LPA Randle interviewed (S1) resident (R1). LPA requested, received, and reviewed the following information: file of R1, Staff roster, Resident roster, and other documents relevant to the investigation. LPA interviewed staff (S2-S6) regarding allegations listed above.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230227115504

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 05/10/2023

NARRATIVE

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Investigation Revealed the following.

Allegation: Staff are not providing resident with a refund.

LPA conducted an interview with S1, S1 denied the allegation. S1 informed LPA that R1 is requesting a refund for clothes that became wet due to water damage from a leak at the facility. S1 stated that R1 was told the facility would launder the clothes and return them to R1. S1 stated that R1 instead took it upon himself to use a dry cleaner when the facility offers cleaning for clothes. S1 stated that there was an ongoing back and forth between S1 and R1, finally in order to move forward S1 put in a request to accounting to reimburse R1 even though there was no provision for such a reimbursement in the admissions agreement or residency agreement. S1’s position what’s that the clothes were damp and a simple washing of the clothes and drying of the clothes would suffice the clothes did not require any type of special care or treatment. R1 was interviewed by LPA regarding the incident R1 stated that although his clothes did not require special treatment, he always use a dry cleaner to clean his clothes and that’s how he wanted them cleaned. R1 stated that although there was reimbursement for such an occurrence in his contract, he felt that the facility was responsible. R1 stated that the matter is resolved because R1 was reimbursed for R1 expense for dry cleaning his clothes.

Based on information gathered, LPA did not find enough evidence to support allegation Staff are not providing resident with a refund.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230227115504

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 05/10/2023

NARRATIVE

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Con't

Allegation:

Staff are not administering residents’ medication in a timely manner

LPA conducted an interview with S1, S1 denied the allegation. LPA ask S1 if R1 was receiving R1’s medication in a timely manner S1 replied “yes” S1 was asked if R1 complained about not receiving his medication in a timely manner S1 stated R1 has complained regarding PRN medication . S1 states that R1 does not like to answer questions regarding specific instructions for giving and receiving PRN medication per physician’s order. S1 states that R1 at times gets upset and walks off refusing to answer questions to receive the appropriate dose of medication. LPA interviewed resident R1 regarding the allegation. LPA asked resident R1 was he receiving his daily medication timely R1's answer was "yes except my PRN". LPA asked resident R1 If he could remember the dates or times that R1 did not receive R1's PRN as requested, answer was "no", R1 stated he did not know the names of staff who denied his medication. R1 stated to LPA that he gets tired of waiting to receive R1’s PRN. R1 stated to LPA R1 does not like to answer questions regarding receiving R1’s PRN R1. R1 stated to LPA "so sometimes I just says forget it (the medication)", R1 stated " I don’t want to answer any questions about my meds". LPA asks R1 if R1 knew the names of staff that were not providing his medication, R1 stated R1 did not know the names just forget it I do not want to answer any more questions regarding my meds. LPA concluded the interview. LPA interviewed staff (S2-S6) regarding Staff are not administering residents’ medication in a timely manner, staff denied the allegation. Residents interviewed denied incidents of not receiving medication timely.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230227115504

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 05/10/2023

NARRATIVE

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Based on information gathered, LPA did not find enough evidence to support allegation, Staff are not administering residents’ medication in a timely manner.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur.

An exit interview was conducted with Aaron Mayes Facility Business Office Director and a hard copy was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: 323-213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC9099 (FAS) - (06/04)

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