198603183-12-7-2021-28-AS-FFIS-C9T7H6-20211217204013

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 12/07/2021
Date Signed: 12/07/2021 11:40:06 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 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
11/30/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211130132816

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: 112	DATE:	12/07/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dennise Torres; Assistant Administrator		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

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Facility staff made inappropriate comments to residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an initial complaint investigation regarding the allegation listed above. LPA met with Assistant Administrator Dennise Torres and explained the reason for the visit.

The investigation revealed the following: LPA obtained copies of Resident & Staff Rosters and interviewed the Assistant Administrator, Resident #1 - Resident #10, and Staff #1 - Staff #4.

The investigation revealed the following: in regards to the allegation "facility staff made inappropriate comments to residents in care", it is alleged that facility staff are telling residents not to leave the facility so often and not to bring the virus in. There were no witnesses to this allegation. Interviews conducted with staff members all denied this allegation. Interviews conducted with staff members revealed that they treat all residents with dignity and respect. Interviews conducted with staff members revealed residents are free to come and go from the facility. Residents are screened upon their return to the facility. Facility staff request residents wash their hands and/or use hand sanitizer upon return from the community. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

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-20211130132816

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: 12/07/2021

NARRATIVE

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LPA observed a group of residents going into the community during the visit.8 out 10 residents interviewed denied this allegation. 8 out 10 residents interviewed indicated that staff members treat them with respect and dignity. 8 out 10 residents interviewed denied staff make inappropriate comments towards them. 8 out 10 residents interviewed indicated that they are free to come and go from the facility as they please. Residents confirmed they are screened upon return to the facility. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021

LIC9099 (FAS) - (06/04)

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