198603183-10-11-2021-28-AS-FFIS-C8KN2T-20211108090513

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 10/11/2021
Date Signed: 10/11/2021 12:00:45 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
01/13/2020 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200113091619

FACILITY NAME:	COUNTRY VIEW ASSISTED LIVING		FACILITY NUMBER:	198603183
ADMINISTRATOR:	ALBA, HELEN		FACILITY TYPE:	740
ADDRESS:	824 W. CAMERON AVE		TELEPHONE:	(323) 309-2026
CITY:	W. COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	136	CENSUS: 105	DATE:	10/11/2021
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Dennise Torres (Administrator)		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff denied resident food.
Staff did not give resident medication in a timely manner.
Staff speaks rudely to residents.
Facility has roaches.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint visit to this facility. The purpose of the visit was to gather information regarding the allegations and to complete the investigation. LPA met with Dennise Torres (Administrator) and explained the reason for the visit.

During the initial visit on 01/16/20, LPA obtained/reviewed a copy of the Staff/Resident roster, Medications administration log for all Resident who are prescribed evening medications and pest control service record, interviewed Staff #1 in the office at 11:23 am, toured the facility (including the kitchen and laundry rooms) with Staff #1 at 11:46 am, interviewed Resident #1 through #11 between 1:23 pm to 3:19 pm in the office.

During today's visit, LPA obtained a copy of the Staff/Resident Roster, toured the facility with Staff #1 at 10:20 am and interviewed Staff #2 to #11 in the office from 10:35 am to 11:20 am.

Continue to LIC9099C.........

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

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 28-AS-20200113091619

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: 10/11/2021

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

In regards to the allegation: Staff denied resident food. LPA interviewed 11 of 11 Residents who indicated they were not denied food. Interviews with 11 of 11 Staff indicate that they did not denied Resident food nor do they know of any Residents being denied food.

In regards to the allegation: Staff did not give resident medication in a timely manner. LPA interviewed 11 of 11 Residents who indicated they receive their medications on time. Interviews with 11 of 11 Staff indicate that they don't know of any Residents who were not given their medications on time. Review of medication logs indicate that administration of medications are properly documented.

In regards to the allegation: Staff speaks rudely to residents. Interviews with 11 of 11 Residents indicate they have not been spoken to rudely by Staff. Interviews with 11 of 11 Staff indicate they have never spoken to Residents rudely nor have they witnessed other Staff speak to Residents rudely.

In regards to the allegation: Facility has roaches. LPA toured the facility during the initial complaint visit and during the subsequent complaint visit and did not observe cockroaches in the facility. Review of pest control documents indicate facility is receiving pest control services on a regular basis. Interviews with 11 of 11 Resident indicate there are no cockroaches in the facility and interviews with 11 of 11 Staff indicate there are no cockroaches in the facility.

Based on LPA's observations, record review and interviews, investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Dennise Torres and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2