198603183-7-18-2023-28-AS-CDCN-CTV2CR-20230718171712

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603183
Report Date: 07/18/2023
Date Signed: 07/18/2023 07:07:23 PM

Document Has Been Signed on 07/18/2023 07:07 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	COUNTRY VIEW ASSISTED LIVING		FACILITY NUMBER:	198603183
ADMINISTRATOR:	SAMUEL DEUTSCH		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:	07/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Dennise Torres, Assistant Administrator		TIME COMPLETED:	05:30 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) Cynthia Chan conducted an annual inspection using the Compliance and Regulatory Enforcement (CARE) tool. LPA met with the Assistant Administrator, Dennis Torres, who assisted with the visit. The facility is licensed to serve 136 non-ambulatory residents ages 60 and over, of which 34 may be bedridden. There is a hospice waiver approved for 20 residents. LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene. Staff are continuing to clean/disinfect at least 4 times a day. Facility has submitted the Infection Control Plan. Facility is aware to report any outbreaks to the appropriate agencies. Operational Requirements: The facility does not accept or retain residents with dementia. There are currently 117 residents residing at the facility. The facility has the sufficient amount of liability insurance covering injury to residents. Physical Plant & Environment Safety: The facility has 68 resident rooms with own bathrooms. There are no swimming pool or bodies of water on the premises. LPA selected 12 random rooms to inspect: #1, #2, #9, #12, #18, #23, #34, #47, #49, #52, #53, and #67. The bedrooms have the required furniture and sufficient lighting. The smoke detectors are interconnected and there are 2 operable carbon monoxide detectors. The facility has a signal system in place. Staffing: Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. There is at least one staff who has CPR and First Aid training on duty and at the premises at all times. There are awake staff during the overnight shift. Personnel Records-Training: Staff files are maintained at the facility. The administrator (Samuel Deutsch) has renewed his certificate but is pending review by the ACS Licensing Division. LPA reviewed 5 personnel records and they have the required documents in file. Continue on LIC809C.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/18/2023

NARRATIVE

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Resident Records-Incident Reports: Resident files are maintained at the facility. LPA reviewed 5 resident records and they have the following documents in their files such as Admission Agreements, Identification & Emergency Information, Physician's Report with TB test results, Pre-admission appraisal, and Resident rights.
Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted by the front entrance.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's capability. There is a full-time Activity Director.
Food Service: LPA observed sufficient food supplies of 2-day perishable and a week of non-perishable items.
Incidental Medical & Dental: The medications are centrally stored in the med room. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed 5 resident medications and they are being administered as prescribed by the physician. Disaster Preparedness: The facility has the updated Emergency Disaster Plan which can be easily accessible by staff. They are conducting different types of emergency drills once a month for various shifts.
Residents with Special Health Needs: The facility does not have a dementia care plan and does not accept any residents with dementia. There are some residents utilizing home health services but none on hospice. The residents who receive insulin injections are able to self administer.

No deficiencies were issued today. An exit interview was held and a copy of this report was given to the assistant administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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