198603183-5-11-2022-28-AS-SCOL-CERT3X-20220525142304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:41:38 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
05/02/2022 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220502154528

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:	05/11/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Dennise Torres; Assistant Administrator		TIME COMPLETED:	02:56 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not treat residents with dignity and respect.

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 stated allegation. LPA met with 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) & Resident #2 (R2) file and obtained copies of FACE Sheet, Physician's Report, and Resident Appraisal. LPA also interviewed Staff #1 - Staff #4 and Resident #1 - Resident #10.

The investigation revealed the following: in regards to the allegation "staff do not treat residents with dignity and respect", it is alleged that facility staff laugh and are rude to the residents. Facility staff allegedly will also slam doors. Staff members interviewed denied the allegation. Staff members interviewed indicated that they treat all residents equally and with respect. Staff members interviewed indicated that they do not slam doors or make fun of residents. Staff members interviewed indicated resident bedroom doors will make a loud noise if not closed carefully and slowly due to their weight and size.

(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

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-20220502154528

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: 05/11/2022

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

8 out of 10 residents interviewed denied the allegation. 8 out of 10 residents interviewed indicated facility staff treat them with respect and dignity. 8 out of 10 residents interviewed indicated that they are happy with their interactions and the services they receive from facility staff. LPA did not observe any staff members slamming doors during today's visit. 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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2