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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: 05/14/2020
Date Signed: 11/17/2020 10:53:22 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2019 and conducted by Evaluator Shawna Day
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190819110959
FACILITY NAME:COUNTRY VILLA TERRACE ASSISTED LIVING CENTERFACILITY NUMBER:
198201010
ADMINISTRATOR:STERN, CHARLESFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 109DATE:
05/14/2020
UNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Sherrina LewisTIME COMPLETED:
11:17 AM
ALLEGATION(S):
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Staff are not showering resident(s) as agreed upon in Admission Agreement.
INVESTIGATION FINDINGS:
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This is an amendment to the 12/20/19 report due to LPA needs to change the deficiency section cited. A citation will still be issued and the findings will remain the same. During the 8/28/19 visit the following was conducted:
STAFF ARE NOT SHOWERING RESIDENTS AS AGREED UPON IN ADMISSION AGREEMENT

LPA interviewed Acting Administrator Glenn Padama, Wellness Coordinator, Sherrina Lewis and Resident #1- 5. LPA reviewed resident files for R#1 - R#3.
Based on various interviews conducted and review of resident showering charts and or Admission Agreemnet packages the Investigation revealed the residents are not being assisted with bathing and/or showering as agreed in the Admission agreements. This was also validated by staff. The LPA finds that the facility failed to shower residents regularly as agreed therefore LPA finds the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Shawna DayTELEPHONE: (323) 981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
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 28-AS-20190819110959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COUNTRY VILLA TERRACE ASSISTED LIVING CENTER
FACILITY NUMBER: 198201010
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2020
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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The facility will submit a plan to CCL to prevent residents not being bathed and/or showered as agreed.
* The facility has hired additional showered help as of 8/27/19.

Corrected at time of visit.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Shawna DayTELEPHONE: (323) 981-3964
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2