198201010-5-4-2023-11-AS-JHAD-CSU29B-20230615171141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:02:02 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
02/23/2023 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230223121746

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:	05/04/2023
		UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Melissa Christopher		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not dispense medication to residents as prescribed
Administrator refuses to communicate with resident’s authorized representative

INVESTIGATION FINDINGS:

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

On 05/04/2023, Licensing Program Analyst (LPA) Perry Scott conducted a continuation of a complaint visit that was done on 03/03/2023. LPA Scott met with Melissa Christopher, administrator, and explained the purpose of this visit is to deliver findings from a previous complaint.

On 3/3/2023, Licensing Program Analyst (LPA) Perry Scott initiated a 10-day complaint investigation at the facility to address the above allegations. LPA conducted a risk assessment prior to entering the facility. LPA was informed that the facility has no COVID cases nor do any of the residents or staff have any symptoms. LPA Scott was met by Vladmir Kaplun (S1), Health and Wellness Director, and the purpose of today's visit was explained.

On 03/03/2023, the investigation consisted of the following:

During today's visit LPA conducted a health & Safety check of the entire facility. LPA conducted interviews with the Health and Wellness Director, Vladimir Kaplun (S1), staff 2-6 and residents 1-6. LPA requested and obtained copies of the following documents: Resident & Staff roster, ID/Emergency information, physicians report, needs and service, and medical administration records for R1.

Report continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

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-20230223121746

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: 05/04/2023

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

The investigation revealed the following:
Regarding allegation #1: Facility staff did not dispense medication to residents as prescribed.

On 03/03/23, LPA interviewed S1. S1 denied the allegation that staff do not dispense residents’ medication as prescribed. S1 stated that all of the med-techs have to adhere to what the doctor orders are and when the medication should be given to the resident. And at no time have they not adhered to those orders. Additionally, S1 stated that there are Medication Administration Records that will corroborate this fact.

On 03/03/23, LPA interviewed S2-S6 about the allegation that staff do not dispense residents’ medication as prescribed. S2-S6 all denied the allegation and asserted that they are following what the doctor has prescribed for each of the residents. And that all medications given with the dates and times are noted in the Medication Administration Record.

On 03/03/23, LPA interviewed R1-R6 about the allegation that staff do not dispense residents’ medication as prescribed. And 6 of 6 residents denied the allegation and confirmed that they are receiving their medication as prescribed.

Based on interviews and records reviewed there is insufficient evidence to support the allegation: Staff do not dispense residents’ medication as prescribed. 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 allegations are Unsubstantiated.

Regarding allegation #2: Administrator refuses to communicate with resident’s authorized representative.

On 03/03/23, LPA interviewed S1. S1 denied the allegation that the Administrator refuses to communicate with resident’s authorized representative.

S1 states that anytime any of the residents’ representatives have questions, issues, or concerns S1s door is always open; and at no time does S1 not respond to a residents’ representative. Additionally, S1 states that S1 is here most days and is not sure why someone would suggest otherwise.

On 03/03/23, LPA interviewed S2-S6 about the allegation that the Administrator refuses to communicate with resident’s authorized representative. S2-S6 all deny that they know of anyone that the administrator has ignored or not responded to.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230223121746

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: 05/04/2023

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

On 03/03/23, LPA interviewed R1-R6 about the allegation that the Administrator refuses to communicate with resident’s authorized representative. 6 of 6 all deny that they know of any instance where the administrator has not responded to a resident’s representative or that they have any personal experience with this allegation.

Based on interviews, observations, and records reviewed there is insufficient evidence to support the allegation: Administrator refuses to communicate with resident’s authorized representative. 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 allegations are Unsubstantiated.

No deficiencies were cited.

An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator, Melissa Christopher.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3