198201010-12-16-2020-11-AS-MVAO-BY4QUA-20210210112822

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 12/15/2020
Date Signed: 12/16/2020 05:02:05 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2020 and conducted by Evaluator Erik Brown

COMPLAINT CONTROL NUMBER: 11-AS-20200518165536

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: 42	DATE:	12/15/2020
		UNANNOUNCED	TIME BEGAN:	12:38 PM
MET WITH:	Sherrina Lewis, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility illegally evicted resident.

INVESTIGATION FINDINGS:

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On this date, Licensing Program Analyst (LPA) Erik Brown conducted an unannounced complaint tele-visit to deliver findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Sherrina Lewis, Administrator.

During the initial telephone visit on 5/22/2020, LPA Brown conducted telephone interviews with Staff #1-2 (S1-2) and Resident #1 (R1). LPA also requested pertinent documentation related to this investigation to be emailed to LPA Brown. LPA received requested documentation from Administrator.

The investigation revealed the following for allegation:

(Facility illegally evicted resident.)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

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-20200518165536

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
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER	FACILITY NUMBER: 198201010
	VISIT DATE: 12/15/2020

NARRATIVE

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Based on interviews with S1-S2 and R1, the eviction notice that R1 was served did not indicate a reason for the proposed eviction. Also, R1 was served the eviction notice personally even though R1 has a Power of Attorney that handles all legal documentation for R1.

Based on LPA Brown’s observations, the records that were reviewed (eviction notice, power of attorney information), and the interviews that were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated.

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

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Erik Brown	TELEPHONE: (747) 230-2283
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

LIC9099 (FAS) - (06/04)

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