198603183-10-26-2021-28-AS-MVAO-CDNT8Y-20220420143106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 10/26/2021
Date Signed: 10/26/2021 11:01:50 AM

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
10/18/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211018104517

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: 110	DATE:	10/26/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dennise Torres; Assistant Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not administer resident's medication as prescribed.
Staff spoke to resident inappropriately.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above allegations. LPA met with Med-Tech Lilian Centeno and explained the reason for the visit. Assistant Administrator Dennise Torres arrived shortly thereafter.

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 #4 (S4) 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 did not administer resident's medication as prescribed", it is alleged that on 10/11/21 a staff member provided a resident with the incorrect medication. Details of the medication error were not provided. Medication error allegation was previously investigated on 10/12/21 and was found to be Unsubstantiated.

(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: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20211018104517

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: 10/26/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

9 out of 10 residents interviewed indicated that they receive their medications as prescribed. Residents interviewed indicated that the facility always has a sufficient supply of their medications available to them. Interviews conducted with staff members denied giving R1 the incorrect medication. Staff members interviewed indicated that they provide residents with their medications as prescribed following doctors orders. Staff members interviewed indicated that they check resident medications to ensure it is correct before it is given to the residents. LPA reviewed a random sample of 6 resident medications and observed medications to be documented properly and given as prescribed. Facility provides ongoing medication training to their medication technicians on an ongoing basis and most recently completed training on 08/26/21. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "staff spoke to resident inappropriately" it is alleged that on 10/12/21 a staff member told one of the residents "you should be grateful that you got your half tablet". No other details were provided. 9 out of 10 residents interviewed indicated that facility staff have not spoken to them inappropriately. Residents indicated that facility staff treat them with dignity and respect. Interviews conducted with staff members all denied this allegation. Staff members interviewed indicated that they treat all residents with dignity and respect and do not make inappropriate comments towards residents. Staff members interviewed also indicated that they have not observed other staff members speak to residents inappropriately. 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 allegation 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: 10/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2