198603183-6-25-2020-28-AS-MVAO-BS6RC4-20200804125343

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 06/25/2020
Date Signed: 06/25/2020 03:23:51 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2020 and conducted by Evaluator Shawna Day

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200618094019

FACILITY NAME:	COUNTRY VIEW ASSISTED LIVING		FACILITY NUMBER:	198603183
ADMINISTRATOR:	ALBA, HELEN		FACILITY TYPE:	740
ADDRESS:	824 W. CAMERON AVE		TELEPHONE:	(626) 962-3511
CITY:	W. COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	136	CENSUS: 108	DATE:	06/25/2020
		UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Samuel Deutsch.		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident's diapering needs are not met
Staff do not keep the facility clean

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shawna Day conducted a subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Samuel Deutsch.
During this investigation LPA interviewed the residents #1 - #8 , Administrator and Staff #1 LPA reviewed copies of resident & staff rosters. LPA also reviewed and observed the facilities lobby, east and west lounges and supply room.

RESIDENTS DIAPERING NEEDS ARE NOT BEING MEET
All staff and residents interviewed were consistent with their statements that the facility always have enough disposable diapers (depends) for the resident whether they have insurance or not, due to the facility gets a large supply from donations and the facilities buys them and insurances. No residents has ever had to use toilet paper in place of a depends. There is always enough for the residents.. LPA observed the supply room and observed approximately 60 boxes of depends of different

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Shawna Day	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

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-20200618094019

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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY VIEW ASSISTED LIVING	FACILITY NUMBER: 198603183
	VISIT DATE: 06/25/2020

NARRATIVE

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sizes with approximately 40 in each box. Administrator informed LPA that another shipment of depends was due to come in today as well.
Based on the interviews conducted and the observation of the LPA there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

STAFF DO NOT KEEP THE FACILITY CLEAN

All staff and residents interviewed were consistent with their statements that the facility is kept clean . There is a cleaning crew that comes in every night and cleans thoroughly, as well as cleaning staff throughout the day. LPA observed the Lobby, west wing lounge and East wing Lounge, front hallways and storage room and found the facility to be clean and sanitary.
Based on the interviews conducted and the observation of the LPA there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

A Telephonic exit interview was held Administrator, and a copy of this report was emailed to Administrator for signature.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Shawna Day	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

LIC9099 (FAS) - (06/04)

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