198603183-1-26-2023-28-AS-TVAO-CPSVWU-20230310154827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:33:49 PM

Substantiated

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
01/23/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230123142717

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: 125	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Dennise Torres - Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff do not follow proper food handling procedures
Staff are not taking universal precautions to maintain a clean environment

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Claudia Cordoba Wellness Director an explained the reason for the visit. Administrator arrived 20 minutes later.

The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster, conducted a tour of the facility's kitchen with Claudia Cordoba wellness director at around 9:45am and 12:00pm and observed refrigerator(s), freezer's, pantry, and staff preparing/serving meals. LPA Flores interviewed resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6), staff #1(S1),#2(S2),#3(S3),#4(S4), administrator, and review 4 staff files and requested copies of food handling certificates.

The investigation revealed the following: Staff do not follow proper food handling procedures. It is alleged cooking, cooling and holding temperatures of food are not maintain.
(CONTINUED LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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 3

Control Number 28-AS-20230123142717

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: 01/26/2023

NARRATIVE

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Interviews with residents revealed 6 out of 6 residents interview stated to not have been sick due to digested food or have been food poison in the last couple of months. Interviews with 5 out of 5 staff interview revealed staff have received food handling training and 2 out of the 5 staff interviewed were aware of proper temperatures for food cooling and maintaining. During the tour of the kitchen at around 12:00pm, LPA Flores requested cook to test the meat tray in steamer maintaining meat warm and temperature tested at 75 degrees F. which is not within department of public health's recommendations for maintaining food warm which is above 135 degrees F. Documents reviewed revealed 4 facility cooks have current/up to date food handling training certificates on file.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding allegation: Staff are not taking universal precautions to maintain a clean environment. It is alleged facility is not maintaining equipment sanitation, employee hygiene, and general sanitation guidelines. Interviews with residents revealed 6 out of 6 residents interview stated to observed staff maintaining cleanness in the dining room and wearing gloves, hairnets, and a face mask when serving meals. Interviews with 5 out of 5 staff interview revealed staff have received food handling training, are aware of proper hygiene, and maintain cleanliness within the kitchen and dining are. During the facility's tour at around 9:45am LPA Flores observed coffee maker's drip tray to have build up mold in the corners and seams. Kitchen's cleaning closet next to the sink area was observed and three live roaches were found two in the floor and one in mopping bucket. In the pantry LPA observed 2 pasta boxes open without properly covering them or storing pasta properly to prevent pest or contaminants from entering. Documents reviewed revealed 4 facility cooks have current/up to date food handling training certificates on file.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

Exit interview was conducted with Dennise Torres Administrator and a copy of this report, LIC 9099D, and appeal rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230123142717

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/27/2023 Section Cited CCR 87555(b)(a)	1 2 3 4 5 6 7	87555 General Food Service Requirements: (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will ensure equipment is in working condition to maintain the temperature of food above 135 degrees F., and will provide in-service training to food handling staff regarding proper cooling, cooking, maintaining food temperatures, storing, and cleaning/sanitizing kitchen by POC due date 1/27/23.
	8 9 10 11 12 13 14	Based on observation, and interviews conducted licensee did not ensure food serve to residents in care is maintain at a proper temperature, temperature in meat tray tested at 75 degrees F., open pasta not stored properly, and equipment not clean properly which poses a health, safety, or personal rights violation to the persons in care.	8 9 10 11 12 13 14
Type B 02/09/2023 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	87555 General Food Service Requirements: (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will provide a copy of pest control service receipt for treatment of roaches in the kitchen to the department by POC due 2/9/23.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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