198603183-4-11-2023-28-AS-RORN-CQTPRY-20230412113331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 09/21/2022
Date Signed: 04/11/2023 09:32:11 AM

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
09/14/2022 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220914084616

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: 117	DATE:	09/21/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Dennise Torres		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff speaks inappropriately to resident in care

INVESTIGATION FINDINGS:

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This report is amended to remove confidential information. There is no change to findings and supporting evidence. LIC9099s delivered on 10/28/22 is a duplicate. LPA Trueman delivered amended report on 4/11/23 and obtained signatures.
Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit regarding the above stated allegation. LPA met with Administrator Dennise Torres and explained the reason for the visit. The purpose of the visit is to investigate the above allegation.
The investigation consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA reviewed Resident #1 (R1) & Resident #2 (R2) file and obtained copies of FACE Sheet, Physician's Report, and Resident Appraisal. LPA also interviewed Staff #1 - Staff #3 and Resident R #3 - Resident R # 8. Resident # 1 and Resident # 2 refused to be interviewed stating that they gave all information to LPA here on a previous complaint.
The investigation revealed the following: in regards to the allegation Staff speaks inappropriately to resident in care. Staff members interviewed denied the allegation. Staff members interviewed indicated that they treat all residents equally and with respect and have not yelled, laughed or called R1 bad names. Staff members interviewed indicated that R1 will make various complaints to licensing and Ombudsman and will call police on many occasions.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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-20220914084616

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: 09/21/2022

NARRATIVE

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States R 1 has difficulty getting along with staff and residents.
Physician's Report dated 04/20/2022 is checked yes for inappropriate behavior.
Interviews with residents revealed that 6 of 6 who were interviewed stated that staff are professional and speak appropriately to residents.
They have never observed staff laughing, yelling or calling residents bad names. Stated they always treat them nicely.
Stated that S1-S3 are nice to them and treat them with respect.
2 of the 6 residents know R 1 and stated that R 1 will complain alot and call on things that have not happened. Stated that police have been called many times and 1x for the air conditioning not working.
Stated that R1 was observed going crying into S2's office and S2 helped to calm her and tried to help her.

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 allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC9099 (FAS) - (06/04)

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