198201010-2-6-2024-11-AS-SCIS-D2P5YC-20240221192208

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 02/21/2023
Date Signed: 02/06/2024 06:47:05 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
01/23/2023 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20230123093650

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:	02/21/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Vladmir Kaplun		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not dispense the resident's medication resulting in hospitalization
Staff do not ensure resident's medication is filled
Staff mismanage resident's medication
Staff did not ensure sanitary handling of the resident’s medication
Staff do not ensure a safe and healthful environment by intimidating residents
Staff do not respond to resident's call buttons timely
Staff did not report UIR as required
Staff do not safeguard resident's property
Staff are on cell phone

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, February 21, 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: During the course of the investigation LPA Bunker Interviewed staff 1-3 (S1-S3) and residents 1-7 (R1-R7) regarding the above allegations. LPA Bunker asked questions relevant to the nature of the complaint. We toured the medication room, observed the resident's medication, MARS in the meds room, and reviewed resident records. Administration records, documentation, and observation of R1's records observed indicated the facility is administering the resident's medications correctly. Staff stated they self-reported the Special Incident Report according to Title 22 Regulations required time frame prior to the complaint allegations.
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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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 4

Control Number 11-AS-20230123093650

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: 02/21/2023

NARRATIVE

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Continued LIC9099-C page 2

Staff 1-3 (S1-S3) and residents 1-7 (R1-R7) stated the Med Techs dispense resident medications according to their physician's directions. LPA Bunker requested copies of supporting documents.

Allegation #1: Staff did not dispense the resident's medication resulting in hospitalization
S1-S3 and R1-R7 stated that Med Tech dispensed the resident's medication according to the doctor's orders.

Allegation #2: Staff do not ensure resident's medication is filled
S1-S3 and R1-R7 stated the Med Tech ensures the resident's medication is filled and residents are not running out of medications.

Allegation #3: Staff mismanage resident's medication
S1-S3 and R1-R7 stated that Med Tech is not mismanaging the resident's medication.

Allegation #4: Staff did not ensure sanitary handling of the resident’s medication
S1-S3 and R1-R7 stated staff is unsure sanitary handling of the resident's medication.

Allegation #5: Staff do not ensure a safe and healthful environment by intimidating residents
S1-S3 and R1-R7 stated staff ensures residents are safe, healthy, and in a comfortable environment. S1-S3 and R1-R7 stated staff is not intimidating residents. S1-S3 and R1-R7 stated the facility has a zero-tolerance rule. Residents are to be free from corporal or unusual punishment, infliction of pain, humiliation, and intimidation. S1-S7 stated they feel safe and happy living here.

Allegation #6: Staff do not respond to resident's call buttons timely
S1-S3 and R1-R7 stated staff does respond to residents' call buttons in a timely manner. R1-R7 stated they had no problem with staff response timely. During the visit, we tested the facility call buttons and they are working and the staff responded to the call buttons.

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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230123093650

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: 02/21/2023

NARRATIVE

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Continued LIC9099-C page 3

Allegation #7: Staff did not report UIR as required
S1-S3 stated residents go to a lot of different doctors. S1-S3 stated resident left and went to the doctor and came back with medications and Med Tech dispensed the medication according to the doctor's orders.

Allegation #8: Staff do not safeguard resident's property
S1-S3 and R1-R7 stated staff does safeguard the resident's property. R1-R7 stated their personal property is locked in their rooms.

Allegation #9: Staff are on their cellphone
S1-S3 and R1-R7 stated staff is not on their cell phones and staff is always available to assist when residents need assistance.

Investigation revealed the following:
Staff Members 1-3 (S1-S3) and Residents 1-7 (R1-R7) interviewed. Both staff and residents have consistently reported that there is no mismanagement of medication within the facility. S1-S3 has affirmed that residents are familiar with their medications, and there is an ongoing dialogue between staff and residents regarding the medications being administered. It has been clarified that the dispensation of medication by staff has not resulted in any hospital admissions for residents.

According to S1-S3, once a physician prescribes medication, it is administered strictly following the physician’s instructions. This procedure has been observed and verified, with Medication Technicians (Med Techs) dispensing medications in accordance with doctor's orders.

S1-S3 and R1-R7 have unanimously stated that medications are filled and managed strictly as per the prescribing doctor's orders, ensuring there is no mismanagement. They also confirmed that medications are handled in a sanitary manner, underscoring the facility’s commitment to maintaining high standards of hygiene.

See LIC9099-C page 4

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230123093650

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: 02/21/2023

NARRATIVE

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Continued LIC812-C page 4

Concerning resident-staff interactions, it has been confirmed by S1-S3 and R1-R7 that staff members maintain a professional demeanor. They do not engage in inappropriate behavior such as placing hands near residents' faces, raising their voices, or exhibiting intimidating behavior. The facility is dedicated to fostering a safe and healthful environment, devoid of any form of intimidation or punitive actions.

The facility adheres to a strict tolerance policy ensuring that residents are protected from corporal or unusual punishment, pain infliction, humiliation, intimidation, ridicule, coercion, threats, mental abuse, or any other punitive actions.

The promptness of staff response to residents' call buttons has been positively noted, as well as the timely reporting of special incidents and Unusual Incident Reports (UIRs) to Community Care Licensing and the appropriate agencies.

Safeguarding of residents' property is a priority, with staff ensuring that personal belongings are protected. Staff members are also compliant with the policy of not using cell phones during work hours, thereby ensuring their full attention is on providing necessary care and supervision to meet residents' needs.
S1-S3 and R1-R7 have categorically denied the allegations made against the staff, reinforcing the commitment of the facility to uphold the highest standards of care and resident safety.

This comprehensive account underscores the facility's adherence to regulatory guidelines and its dedication to ensuring the well-being and safety of its residents through proper medication management, respectful and professional staff conduct, and a steadfast commitment to creating a nurturing environment.

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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

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