198603183-10-12-2021-28-AS-MVAO-CC6SWL-20220303131432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 10/12/2021
Date Signed: 10/12/2021 12:22:59 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
10/07/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211007160645

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: 105	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dennise Torres; Assistant Administrator		TIME COMPLETED:	12:38 PM

ALLEGATION(S):

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Staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

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

The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA reviewed Resident #1 (R1) file and obtained copies of FACE Sheet, Physician's Report, and Resident Appraisal. LPA interviewed Staff #1 (S1) - Staff #2 (S2) and Resident #1 (R1) - Resident #10 (R10). LPA also reviewed a random sample of resident medications during today's visit.

The investigation revealed the following: in regards to the allegation "staff mismanaged resident's medication", it is alleged that facility staff members gave R1 the wrong medication. R1 is unable to recall the name of the medication or the day of the alleged incident. 9 out of 10 residents interviewed indicated that they receive their correct medications as prescribed. Residents interviewed indicated that facility has their prescribed medication available to them at all times.

(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: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

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-20211007160645

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: 10/12/2021

NARRATIVE

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Interviews conducted with staff members denied giving R1 the incorrect medication. Staff members interviewed indicated that they provide residents with their medications as prescribed based on doctors orders. LPA reviewed a random sample of 5 resident medications and observed medications to be documented properly and given as prescribed. S1 and S2 receive ongoing medication training and most recently completed 8 hours of Med Aide Certification training on 08/26/21. Therefore there was insufficient evidence to corroborate with the 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: 10/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

LIC9099 (FAS) - (06/04)

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