198201010-2-24-2021-11-AS-MVAO-BYQMXP-20210302090014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201010
Report Date: NO Visit Data Available
Date Signed: 02/24/2021 10:09:29 AM

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
and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201019104307

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: 58	DATE:
		UNANNOUNCED	TIME BEGAN:
MET WITH:	Sherrina Lewis, Administrator		TIME COMPLETED:

ALLEGATION(S):

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Staff speak inappropriately to resident in care
Residents needs are not being met
Resident's wheelchair does not fit through the bathroom door in the bedroom

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Sherrina Lewis, the facility administrator.

The investigation consisted of following: Interviews and Record reviews. On 10/28/20, LPA Soto interviewed Administrator Sherrina Lewis. On 02/12/21, LPA Soto interviewed R#1 – R#7 and S#2 – S#7. LPA Soto received the following documents on 11/02/20 from administrator: Resident roster, Staff roster, repair invoice, plan of repairs, Pre-Placement, Appraisal/Needs and Services Plan, Physician’s, Mars Logs for October, Progress Notes, 2 Sirs’ dated 10/18/20 & 10/20/20.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE:

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE:

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-20201019104307

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: 02/19/2021

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following. For Allegation #1 – Staff speak inappropriately to resident in care. Interviews conducted with residents R#1 - R#6 all denied being yelled or spoken to inappropriately. Residents R#1 – R#6 all agreed that the staff treats them good and are very nice. Interviews conducted with administrator and staff, all agree that none of them have yelled or spoken to residents inappropriately or heard any staff speak to residents inappropriately. Residents, Administrator and staff interviews do not concur with the above allegation.

Allegation #2 - Residents needs are not being met. & Allegation #3 - Resident's wheelchair does not fit through the bathroom door in the bedroom. Interviews conducted R#1 – R#7 stated that all their needs have been met and never seen or heard of any resident have had trouble with their wheelchair not fitting in their room or bathroom. Interviews conducted with S#2 – S#7, stated that they always help the residents when they ask for help. They meet all the resident’s needs. The Administrator stated that R#1 was transferred temporarily to a different room because she was having R#1 room and bathroom remodeled with fresh new paint and new flooring. She wanted to surprise the resident. R#1 had gone to the hospital and when R#1 returned to the facility, he was put in a new room and his belonging where packed and stored for the 2 weeks it would take to remodel his room. R#1 was made of aware of why R#1 was moved and returned to his original room a week later. All R#1 belongings and furniture where return to the room. Residents, Administrator and staff interviews do not concur with the above allegations.

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

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

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021

LIC9099 (FAS) - (06/04)

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