198603183-8-27-2021-28-AS-MVAO-CASSW3-20220118131339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 06/08/2021
Date Signed: 08/27/2021 11:48:39 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
03/15/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210315135219

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: 95	DATE:	06/08/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Dennise Torres; Assistant Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff is putting a foreign substance in resident's bed.
Facility is not maintaining an odor free environment.
Resident has had items from her room stolen.
Resident sustained a fracture.
Resident medications are mixed with something foreign.

INVESTIGATION FINDINGS:

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*This is an amended version of the report dated 06/08/21. The reason for amendment is the initial report contained confidential information that has now been removed. No other changes have been made to the report.*

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

The investigation consisted of the following: during the initial televisit conducted on 03/23/21, LPA interviewed Assistant Administrator and Staff #1 (S1) - Staff #3 (S3). LPA also requested copies of resident & staff rosters and documents from Resident #1's file. During today's visit, LPA once again interviewed S1 - S3 and additionally interviewed Staff #4 - Staff #5 and Resident #1 - Resident #9.

The investigation revealed the following: in regards to the allegation "staff is putting a foreign substance in resident's bed", it is alleged that staff spray something on R1's bed which is a thin glass that sticks to her skin and hurts. During today's visit, LPA toured R1's bedroom and did not observe any foreign substance on R1's bed. (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: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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-20210315135219

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: 06/08/2021

NARRATIVE

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Interviews conducted with staff members revealed that they do not spray any foreign substance on R1's bed. Interviews conducted with residents revealed that facility staff does not spray their beds with any type of foreign substance. Therefore there was insufficient evidence to corroborate this allegation.

In regards to the allegation "facility is not maintaining an odor free environment", it is alleged that R1's roommate puts her dirty diapers in the garbage can and the room smells bad. During today's visit, LPA toured R1's bedroom and a random sample of resident bedrooms and did not smell a bad odor coming from any of the rooms. R1 does not currently have a roommate. Interviews conducted with staff members revealed that staff is required to place dirty diapers in a sealed plastic bag and remove the diaper from residents rooms. Trash cans located in resident bedrooms are also cleaned out daily. Interviews conducted with residents revealed that facility is odor free. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "resident has had items from her room stolen", it is alleged that R1 sleeps during the day and people come in and steal her things. It is unknown if it is staff or residents who steal R1's belongings. LPA obtained a copy of R1's Resident Personal Property and Valuables Inventory List. During tour of R1's bedroom, LPA observed R1 has a locked cabinet in her bedroom to which she has they key for. Interviews conducted with staff members revealed that they do not steal from any of the residents. Interviews conducted with residents R2 - R9 have not had any items stolen from their room. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "resident sustained a fracture", it is alleged that R1 has tripped on the facility sprinklers and has been injured, the last time she broke some ribs. Per interview with Assistant Administrator, it was revealed that on 02/02/21 R1 was hospitalized due to chest pain from an alleged unwitnessed fall she had suffered about 3 or 4 months prior. R1 was transported to Queen of The Valley Hospital were she was diagnosed with a fractured rib. Prior to this hospitalization, facility was unaware of the fall as R1 had not informed staff. Facility staff did not observe this fall. Based on information available, facility took the proper steps by calling 911 immediately and notified R1's Conservator and Primary Care Physician of the incident once facility was aware of the incident. Therefore there was insufficient evidence to corroborate with this allegation.

(CONTINUED ON 9099C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210315135219

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: 06/08/2021

NARRATIVE

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In regards to the allegation "resident medications are mixed with something foreign", it is alleged that R1's medications are mixed with something foreign. No other details provided. LPA reviewed a random sample of resident medications and observed that medications are documented properly and given as prescribed. LPA also observed medications to be placed in their original packaging/containers. Interviews conducted with staff members revealed that resident medications are not mixed with anything foreign. Interviews conducted with residents revealed that they receive their medications as prescribed. 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 allegations. Although the allegations may have happened or are 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 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: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

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