198603183-12-22-2021-28-AS-SCOL-CDESE4-20220412134806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 12/22/2021
Date Signed: 12/22/2021 04:04:51 PM

Unsubstantiated

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
12/14/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211214161817

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: 113	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Dennise Torres; Assistant Administrator		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Staff refuses to schedule transportation services for residents' medical appointments.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Assistant Administrator Dennise Torres and Administrator Samuel Deutsch 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) & Resident #2 (R2) file and obtained copies of FACE Sheet, Physician's Report, and Resident Appraisal. LPA interviewed Administrator, Assistant Administrator, Staff #1 (S1) - Staff #3 (S3) and Resident #1 (R1) - Resident #9 (R9).

The investigation revealed the following: in regards to the allegation "staff refuses to schedule transportation services for residents' medical appointments", it is alleged that facility staff are canceling R1 and R2 medical transportation appointments and staff refuse to help residents schedule any other type of transportation.

(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: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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-20211214161817

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: 12/22/2021

NARRATIVE

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R1 and R2 both confirmed that they arrange their own transportation to medical appointments and do not require assistance from facility staff. 7 out of 9 residents interviewed indicated facility staff will assist them with scheduling transportation to their medical appointments. 7 out of 9 residents interviewed indicated facility staff have not canceled their transportation to their medical appointments. All staff members interviewed indicated that they have not canceled transportation for residents. Residents will usually use their insurance transportation services for their medical appointments, but facility will also arrange Uber/Lyft transportation for residents if needed. LPA reviewed a "Transportation Log" that the facility keeps on file which documents arrangements of transportation services that facility staff have assisted residents with. Assistant Administrator also provided LPA with Uber Invoice dated 12/16/21 indicating that transportation was arranged for R1's most recent medical appointment after the insurance transportation service failed to show up. R1 confirmed this as being accurate. 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: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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