198603183-3-7-2022-28-AS-LHIS-CCXQ87-20220328115617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 03/07/2022
Date Signed: 03/07/2022 03:10:11 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
02/28/2022 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220228145210

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: 114	DATE:	03/07/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Dennise Torres, Asst. Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Facility failed to meet resident's medical needs
Facility is falsifying resident's documents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint visit in response to the above allegations. LPA met with Assistant Administrator, Dennise Torres who assisted with today's visit.

Regarding the allegation that (1) Facility failed to meet resident #1's medical needs and (2) Facility is falsifying resident #1's documents, the investigation consisted of the following: Interviews with Assistant Administrator and Staff #1, Interviews with Resident #1 - Resident #9, and review of specific documents from Resident #1's file. Facility staff interviewed stated that they do not refuse any medical personnel from coming to see any of the residents. Staff denied that they have refused any medical personnel from coming to see Resident #1. Staff interviewed stated that they assist residents with their medical needs. Staff denied that they have falsified any residents documents. Residents interviewed were unable to corroborate the allegations. They stated that the facility does assist them with their medical needs. Residents interviewed stated that the facility does allow medical personnel to see residents in the facility. Residents interviewed stated that the facility is not falsifying their documents to their knowledge.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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-20220228145210

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: 03/07/2022

NARRATIVE

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8 out of 9 residents stated that the facility does assist them with their medical needs. 9 out of 9 residents stated that facility is not falsifying their documents.

Based on LPA's observations and interviews, investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator, Dennise Torres.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC9099 (FAS) - (06/04)

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