198603183-8-2-2022-28-AS-NMAN-CGWRPG-20220802131155

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603183
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:52:39 PM

Document Has Been Signed on 08/02/2022 04:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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:	08/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Staff Leslie Rivas		TIME COMPLETED:	01:15 PM

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

Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with staff Leslie Rivas. Assistant Administrator Dennise Torres arrived shortly after. LPA explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been approved. The facility cares for elderly residents and is allowed to have 20 hospice residents.
LPA and Administrator toured the facility which included a random sample of resident rooms along with the kitchen, dining room, both laundry rooms, storage room, and large/movie room. The patio area is well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the patio area. Passageways and exits are free of obstruction. The common areas are clean and have the required furniture. There is a screening station at the entrance of the facility. Staff conducted a routine symptom screening of LPA at the time of entrance and have a sign-in policy as required per COVID-19 procedures. Randomly chosen resident bedrooms were toured. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The water temperature was tested in a random selection of resident bathrooms. The hot water was between 106.6 - 113.7 degrees which is within the required 105 - 120 degrees. Cleaning supplies were observed inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. Smoke detectors and carbon monoxide detector were working properly, fire extinguishers were fully charged and operational. LPAs observed the centrally stored medication area to be locked and inaccessible to clients. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

Continue 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/02/2022

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

LPA reviewed 6 resident records to confirm emergency contact is updated, physician's reports are on file, and admission agreements are complete. Five staff records were reviewed to confirm health screenings, training and fingerprint clearances. LPA reviewed 3 residents' medications. Medications are documented properly and given as prescribed. First Aid kit was fully stocked with current manual.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2