198603183-3-29-2022-28-AS-MVAO-CFDUFN-20220614153301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 03/29/2022
Date Signed: 03/29/2022 01:12:47 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
03/21/2022 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220321100914

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: 116	DATE:	03/29/2022
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Dennise Torres; Assistant Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff pushed resident.
Staff made inappropriate comments towards resident.
Staff did not provide transportation for resident.
Staff did not safeguard residents personal belongings.
Staff are not providing resident with their mail.

INVESTIGATION FINDINGS:

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

The investigation consisted of the following: LPA requested copies of Resident & Staff Rosters and conducted a tour of facility and common areas. LPA reviewed files for Resident #1 (R1) - Resident #2 (R2) and requested copies of the following documents: Identification and Emergency Information Sheets, Physician Reports, Resident Personal Property and Valuables Sheet, Resident Appraisals, Transportation Log for March, and Incident Reports for the months of February & March. LPA also interviewed Resident #1 - Resident #10 and Staff #1 - Staff #4.

The investigation revealed the following: in regards to the allegation "staff pushed resident", it is alleged that a facility staff member pushed R1 without R1 suffering any injuries. Specific details of the alleged incident were not provided. Interview conducted with 4 of 4 staff members all denied the allegation. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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-20220321100914

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: 03/29/2022

NARRATIVE

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Staff members interviewed indicated that they have never pushed any resident nor have they observed any other staff member push any of the residents. 8 out of 10 residents interviewed also denied the allegation. 8 out of 10 residents interviewed indicated that facility staff treat them with dignity and they feel safe at the facility and residents interviewed indicated they have never observed staff members push any of the residents. Therefore there was insufficient evidence to corroborate with the allegation.

In regards to the allegation "staff made inappropriate comments towards resident", it is alleged that facility staff are mean and make inappropriate comments such as calling residents "unbalanced and crazy". Interviews conducted with 4 out of 4 staff members all denied the allegation. Staff members interviewed indicated they have not made inappropriate comments towards residents. 8 out of 10 residents interviewed denied the allegation. 8 out of 10 residents interviewed indicated facility staff treat them with respect and have not made inappropriate comments towards them. Therefore there was insufficient evidence to corroborate with the allegation.

In regards to the allegation "staff did not provide transportation for resident", it is alleged that facility staff keep cancelling R1 rides to doctor's appointments. Interviews conducted with 4 of 4 staff members denied this allegation. Staff members interviewed indicated that they have not canceled any resident transportation appointments. Facility staff usually assist residents with arranging transportation services via their medical providers, however facility staff will also arrange Uber/Lyft transportation if necessary. R1 confirmed that she arranges her own transportation to medical appointments and does not require assistance from facility staff. 8 out of 10 residents interviewed indicated facility staff assist them with arranging transportation services to their medical appointments. LPA obtained a copy of Resident Appointments that the facility keeps on file which documents the transportation services that have been arranged by facility staff for resident appointments. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegations "staff did not safeguard residents personal belongings" and "staff are not providing resident with their mail", it is alleged that R1 and R2 are not getting their mail and that it is being returned to sender. It is also alleged that facility lost R2 phone bill. Interviews conducted with 4 out of 4 staff members revealed that facility staff distribute the mail to residents the same day received and that there have been no issues or complaints brought to their attention regarding mail. 8 out of 10 residents interviewed indicated that they do not have any issues with receiving mail at the facility. R2 also confirmed during interview that she did receive her phone bill from facility. 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 allegations are 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: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC9099 (FAS) - (06/04)

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