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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 08/03/2020
Date Signed: 08/03/2020 02:50:31 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
06/24/2020 and conducted by Evaluator David Sicairos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200624104402
FACILITY NAME:COUNTRY VIEW ASSISTED LIVINGFACILITY NUMBER:
198603183
ADMINISTRATOR:ALBA, HELENFACILITY TYPE:
740
ADDRESS:824 W. CAMERON AVETELEPHONE:
(626) 962-3511
CITY:W. COVINASTATE: CAZIP CODE:
91790
CAPACITY:136CENSUS: 114DATE:
08/03/2020
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Denisse TorresTIME COMPLETED:
12:07 PM
ALLEGATION(S):
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Facility has roaches.
Food service is inadequate.
Facility not providing entertainment to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Sicairos initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Assistant Administrator Denisse Torres.

The investigation consisted of the following: During initial televisit conducted on 07/01/20, LPA conducted a virtual tour of the facility with the assistance of Assistant Administrator. LPA also interviewed Staff #1 (S1) and Staff #2 (S2) and obtained copies of resident & staff rosters. On 07/30/20, LPA conducted phone interviews with Staff #3 (S3) and Resident #1 - Resident #9 (R1 - R9). Resident #10 (R10) refused to be interviewed.

The investigation revealed the following: in regards to the allegation "facility has roaches", it is alleged that there are roaches in the hallway, the "west wing" of the facility, the kitchen, the pool room and the laundry room.
(CONTINUED ON 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2020
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-20200624104402
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: 08/03/2020
NARRATIVE
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This allegation was previously investigated on report dated 06/16/20 with Unsubstantiated Findings. Facility Administrator provided several Terminix invoices demonstrating that facility is continuing to receive preventative spraying services every other week. All residents interviewed indicated that they have not observed any roaches at the facility. All residents interviewed expressed being happy about the cleaning that is done at the facility. Staff members interviewed denied that the facility is infested with roaches and indicated that deep cleaning is done on a day-to-day basis. Therefore, there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "food service is inadequate", it is alleged that some of the residents are not provided utensils to eat with during food service, and when they ask for them they do not get them, so they don't eat and end up throwing the food away because they can't eat it. Interviews conducted with staff members all indicated that residents are currently receiving food service to their rooms. Staff members interviewed indicated that residents are all provided with a spoon, fork, and knife wrapped in a napkin during each meal. Interviews conducted with residents all indicated that they receive the proper utensils needed to eat all of their daily meals. Residents also indicated that staff has never refused to provide them with utensils. Therefore, there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "facility not providing entertainment to residents", it is alleged that residents are not allowed to watch TV in the living room, and when they ask staff if they can turn it on, they are told no. During facility virtual tour conducted on 07/01/20, LPA observed the facility "Living/TV room" area. TV was on and there were designated seating areas in order to enforce social distancing between residents. All residents interviewed indicated that they are allowed to watch TV and have not been denied the right to do so by staff. Residents interviewed also indicated that facility provides residents with other entertainment options such as bingo or crossword puzzles and coloring books. Interviews conducted with staff members all denied that they have refused to allow residents to watch TV. Therefore, there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, clients, review of client 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.

Telephonic exit interview held, and a copy of this report was emailed to Administrator & Assistant Adminstrator for signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2