198603183-12-1-2022-28-AS-MVAO-CPBVKX-20230223153101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:04:33 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/28/2022 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221128102150

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: 120	DATE:	12/01/2022
		UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	.Claudia Cordoba Wellness Director Denise Torres. Assistant Admistrator		TIME COMPLETED:	03:13 PM

ALLEGATION(S):

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Staff threw an object at resident
Staff intimidates resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Alberto Lopez conducted the initial complaint investigation for the allegations listed above. LPA met with Wellness Director, Claudia Cordoba and explained the purpose of the visit. Assistant Admistrator Denise Torres arrived a short time later and assisted LPA with the investigation.

During the visit today, LPA toured the facility and obtained copies of the staff/resident roster, Resident #1 (R1) Physician’s report (LIC602A), and SIR dated 11/28/22 and 11/30/22. LPA interviewed Staff #1-Staff #7 (S1-S7) and Resident #1-#12 (R1-R12) and attempted to interview Resident #13 (R13 but declined to speak with the LPA.
****REPORT CONTINUED ON LIC 9099-C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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-20221128102150

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COUNTRY VIEW ASSISTED LIVING	FACILITY NUMBER: 198603183
	VISIT DATE: 12/01/2022

NARRATIVE

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Regarding Allegation: Staff threw an object at resident. It is alleged that S2 threw boxes at R1 and took R1 tablet and hit R1 with it. R1 stated that it did occur and provided name of witnesses (S6-S7). During phone interview, R1 recanted all the allegations and stated R1 did not say anything to anyone and to erase everything. R1 refused to be seen in person during phone call and told LPA she will not open her door. S2 denied the allegations and stated that she has no interaction or responsibilities with R1 due to ongoing false accusations. S6 stated she did not witness any incidents that included residents getting boxes thrown at them or being hit as S6 would have reported it immediately. S7 denied that she witnessed any staff hitting or throwing objects at R1. S7 stated she would have reported the incident right away. 7/7 staff denied the allegations. 11/12 staff did not collaborate the allegations. 11/12 residents stated that they have never witness any staff striking a resident or throwing objects at them.

Regarding Allegation: Staff intimidates resident. It is alleged that staff intimidates resident because they want to kick her out. R1 recanted this allegation during phone interview and 12/12 residents could not collaborate the allegations. 7/7 staff interviewed denied the allegations. Staff stated that R1 has history of making false accusations and later recanting them.

Based on statements, record reviews and interviews conducted with staff and residents, 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 that the alleged violation did nor did not occur, therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of the report and appeal rights was provided to the Assistant Administrator, Denise Torres

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC9099 (FAS) - (06/04)

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