198603183-8-23-2023-28-AS-FFIS-CV94TV-20230831192347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 08/23/2023
Date Signed: 08/23/2023 01:58:33 PM

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
03/24/2022 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220324140017

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: 124	DATE:	08/23/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Dennise Torres (Administrator)		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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1: Questionable death of residents.
2: Staff made an inappropriate comment towards residents.
3: Staff not responding to calls for assistance in a timely manner.
4: Staff not treating resident's equal.
5: Meals are not of quality or quantity.
6: Meals are served on damaged plates.
7: Staff not ensuring that resident's are fed.
8: Facility not providing activities for residents.
9: Resident's are threatened with eviction notices.
10: Staff are not properly managing resident's medications.
11: Staff disposing of resident's medication.
12: Medication records are inaccurate.
13: Staff teasing resident's.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with Dennise Torres (Administrator) and explained the purpose of the visit.

During the initial complaint visit conducted on 03/28/22, LPA obtained/reviewed a copy of the Staff Roster, Resident Roster, Resident #13's death report and death certificate. LPA interviewed Staff #1 and #2 in the office, toured the kitchen and dining room with Staff #2 and interviewed Residents #1 to #12 in the office.

During today's visit, LPA obtained a copy of the Staff/Residents rosters, food menu, activity calendar, interviewed Staff #1 to #8 in the office and reviewed medication records for 12 random Residents.

Continue to LIC9099C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

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 4

Control Number 28-AS-20220324140017

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: 08/23/2023

NARRATIVE

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Regarding allegation #1: Questionable death of residents. Record review and interviews with Staff and Residents indicate there was one Resident (R#13) death within the time frame of this complaint. LPA reviewed death certificate for R#13 which does not indicate death to be questionable. LPA reviewed facility death reports and does not indicate alleged multiple Resident deaths within the time frame of this complaint.

Regarding allegation #2: Staff made an inappropriate comment towards resident's. Interviews with 8 of 8 Staff indicate they have never made an inappropriate comment towards a Resident and never witnessed other Staff making inappropriate comments towards Residents. Interviews with 12 of 12 Resident also indicate Staff has never made inappropriate comments towards them or witnessed Staff making inappropriate comments towards Residents.

Regarding allegation #3: Staff not responding to calls for assistance in a timely manner. LPA verified the facility alert system to be operable. Interviews with Staff responsible for providing assistance to Residents indicate calls are being responded in a timely manner. Every care giving Staff is provided with a walky talky for notifications when a Resident is in need of assistance. Interviews with Residents who uses the call cord also indicate Staff is responding to Resident's calls in a timely manner.

Regarding allegation #4: Staff not treating resident's equal. Interviews with 8 of 8 Staff indicate they are treating Residents equally. Interviews with 12 of 12 Residents also indicate they are being treated equally.

Regarding allegation #5: Meals are not of quality or quantity. LPA toured the kitchen and observed meals are of good quality and quantity. Food menu indicate meals are of good quantity and quality. Interviews with Staff responsible for food service and Staff who witness food services indicate food is of good quality and quantity. Interviews with 12 of 12 Residents also indicate meals are of good quality and quantity.

Regarding allegation #6: Meals are served on damaged plates. LPA toured the kitchen and did not observe damaged plates. Interviews with kitchen Staff and Staff who witness food services indicate meals are not served on damaged plates. Kitchen Staff indicate damaged plates are discarded and replaced. Interviews with 12 of 12 Residents indicate meals are not served on damaged plates.

Continue to LIC9099C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20220324140017

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: 08/23/2023

NARRATIVE

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Regarding allegation #7: Staff not ensuring that resident's are fed. Interviews with 8 of 8 Staff indicate Residents are ensured to be fed. Interviews with 12 of 12 Resident also indicate Staff ensures they are fed.

Regarding allegation #8: Facility not providing activities for resident's. Review of the activity calendar indicate Residents are provided with activities. Interviews with Staff indicate Residents are being provided with activities. Interviews with 12 of 12 Residents also indicate activities are provided.

Regarding allegation #9: Resident's are threatened with eviction notices. Interviews with Staff indicate Residents have never been threatened with eviction. Interviews with 12 of 12 Resident also indicate Staff has never threatened them with eviction.

Regarding allegation #10: Staff are not properly managing resident's medications. Interviews with Staff responsible for medication assistance indicate medication are properly managed. Review of medication records also indicate medications are properly managed. Interviews with 12 of 12 Resident also indicate their medications are properly managed.

Regarding allegation #11: Staff disposing of resident's medication. Medication record review indicate Staff dispose of medications based on physician's order. Interviews with Staff responsible with medication assistances indicate medications are disposed based on physician's order or Residents who may have refused to take their medications or Resident was in the hospital and Staff was unable to provide them with medications.

Regarding allegation #12: Medication records are inaccurate. Review of medication records for random Residents indicate medication assistance is documented accurately. LPA did not observe any discrepancies. Interviews with Staff responsible with medication assistance also indicate medication records are accurately documented on the computer or on paper.

Regarding allegation #13: Staff teasing resident's. Interviews with 8 of 8 Staff indicate they have never teased a Resident or have they witnessed other Staff tease a Resident. Interviews with 12 of 12 Resident also indicate they have never been teased by Staff nor have they witness Staff tease other Residents.

Continue to LIC9099C...

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20220324140017

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: 08/23/2023

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 26 27 28 29 30 31 32	Based on LPA's record review, observations and interviews, the complaint investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview conducted with Dennise Torres (Administrator) and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4