198603183-3-24-2023-28-AS-MVAO-CRUQV9-20230515122957

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 03/24/2023
Date Signed: 03/24/2023 12:40:24 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
03/21/2023 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230321094926

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:	03/24/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Denise Torres		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff are refusing to let residents go to appointments
Staff denied resident food
Staff smashed residents plate of food
Staff don't treat residents with dignity

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Christine Wong and Tena Herrera conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegations and to establish the validity of the complaint. LPAs met with Staff #1 Wellness Director Claudia Cordoba who allowed entry into the facility and was later met by Assistant Administrator Denise Torres who assisted with the visit.

The investigation consisted of the following: On today's date, LPAs interviewed administrator, five staff (S1-S5) and eleven residents (R2-R13) and obtained copy of documents include resident and staff roster and some documents for Resident#1 (R1) include face sheet, resident appraisal, physician report, needs and service plan and progress notes and incident reports dated on 11/28/22 and 11/30/22, faciltiy menu and staff training log on food service and sexual harrassment.

(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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-20230321094926

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: 03/24/2023

NARRATIVE

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The investigation revealed of the following: Allegation#1 "Staff are refusing to let residents go to appointments." LPAs interviewed 11 residents and 10 out of 11 residents denied the allegation and stated they can go in and out the facility freely. Staff never refused them to go to the appointments and staff never asked any questions as residents would let the staff where they are going or when they would be back to the facility. It is because sometimes staff may have to pack residents' medication if they go out for a longer time. Staff also denied the allegation and reported the facility is an open facility and residents have their right to go in and out the facility freely. Assistant Administrator indicated that unless residents' are not permitted to go out alone and its documented on residents' physician report.

Allegation#2 "Staff denied resident food" LPAs interviewed 11 residents and 10 out of 11 residents denied the allegation and reported they never had any issues for food in the facility. They are always able to get sufficient food in the facility. They get three meals a day and snacks. They are also able to get second if they want more. Staff never denied resident food. LPAs interviewed staff and they all denied the allegation. Staff reported residents always can get second if they want and they would offer alternative menu for residents if residents do not like the menu of the day. Staff never denied food for residents.

Allegation#3 "Staff smashed residents plate of food" LPAs interviewed 11 residents and 10 out of 11 residents denied the allegation and reported they never witnessed any staff smashed residents the plate of food. Residents stated only residents would do it if they were not able to get what they want or residents would spill the food or drinks on the floor. LPAs interviewed staff and all denied the allegation and reported they never witnessed any staff doing it and staff would have never done it to the residents.

Allegation#4 "Staff don't treat residents with dignity" LPAs interviewed 11 residents and 10 out of 11 residents denied the allegation and reported staff are nice and respectful and staff had never being mean or yelled at them. LPAs interviewed staff and denied the allegation and reported they never witnessed any staff in the facility not treat residents with dignity. Every staff in the facility are very respectful to residents. No staff in the facility would allow not being respectful or mean to the residents.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230321094926

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: 03/24/2023

NARRATIVE

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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 allegations are UNSUBSTANTIATED.

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

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

LIC9099 (FAS) - (06/04)

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