198201010-2-1-2021-11-AS-AJKK-BY62DT-20210211161851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 01/29/2021
Date Signed: 02/01/2021 03:42:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2020 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20200715134923

FACILITY NAME:	COUNTRY VILLA TERRACE ASSISTED LIVING CENTER		FACILITY NUMBER:	198201010
ADMINISTRATOR:	PADAMA, ANTHONY		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS: 47	DATE:	01/29/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Sherrina Lewis		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mismanaged resident's medications on several occasions

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Lourdes Montoya conducted a subsequent complaint visit to deliver findings for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Sherrina Lewis, the Residential Care Director.

Investigation consisted of the following: A virtual inspection of the physical plant; Telephone interview with three (3) staff and six (6) residents; and review of current staff/resident roster, physician's report, needs services plan, MAR, and admission agreement.

REPORT CONTINUED IN LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021

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 2

Control Number 11-AS-20200715134923

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 01/29/2021

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

Allegation: Staff mismanaged resident's medications on several occasions

It is alleged staff mismanaged resident’s medications on several occasions. Based on interview, Resident #1 claims he had three prescriptions that were either missing, misplaced or depleted. Resident #1 admitted he did not experience any adverse effect from missing dosages of those medications.

Based on record review, the three medications in question are all listed in the Medication Administration Records (MAR) of Resident #1. The department reviewed MARs dated 5/1/20-5/31/20, 6/1/20-6/30/20 and 7/1/20-7/31/20. All these records indicate Resident #1 did not miss any dosage except for July 15, 2021 at 5:00 pm. Staff #1 explained on July 15, 2020 while Resident #1 was taking his medications, he dropped the pill (Lasix). Assigned staff prepared another Lasix pill but Resident left and did not take it.

The Department conducted interviews with Residents #1-#6 and Staff #1-#3 from this facility. Residents #2, #3, #5 and #6 denied their medications were mismanaged by staff. Resident #4 stated he does not take any medications. According to interview with Staff #1, who relieves nurses and medication technicians in administering medications, medication sizes, shape and color change depending on the manufacturer. Staff #1 explained further that Resident #1’s medication may have changed in color and he probably thought he did not take the medications. Staff #1 also stated Veterans Pharmacy medication refill process takes about 10 days and due to the Covid-19 pandemic, refill processes take longer. Staff #2 and #3, who assist residents with medication preparation and administration, mentioned that there were no residents who complained about missing or misplaced medications. Staff #2 and #3 also stated that they call pharmacies for refills two weeks before the medications run out. Staff #1, #2 and #3 denied staff mismanaged Resident #1’s medications. The department did not find sufficient evidence to corroborate the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation, “Staff mismanaged resident's medications on several occasions”. This is evidenced by LPA’s observations, interviews with staff and residents and reviews of records.

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 UNSUBSTANTIATED.

A telephonic exit interview was conducted with Residential Care Director Sherrina Lewis, and an electronic copy was provided via email for signature.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (323) 981-4934
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2