198603183-6-13-2023-28-AS-TVAO-CWPL9C-20231017083314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 06/13/2023
Date Signed: 06/13/2023 03:36:32 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
09/27/2022 and conducted by Evaluator Joe Katrdzhyan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220927150112

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: 127	DATE:	06/13/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Wellness Director / Claudia Cordoba Administrator / Dennise Torres		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff are not transporting resident to appointments

Staff are not providing residents with mail in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Wellness Director / Claudia Cordoba and was later joined by the Administrator / Dennise Torres, who assisted with the visit. LPA explained the purpose of today’s visit is to discuss the above-mentioned allegations of Staff are not transporting resident to appointments and Staff are not providing residents with mail in a timely manner.
• The allegation of “Staff are not transporting resident to appointments” was previously investigated and addressed by LPA David Sicairos on 12/22/21, Control #28-AS-20211214161817 and on 8/27/21, Control #28-AS-20210820151018. The findings were delivered as Unsubstantiated, during both visits. Please refer to Control #28-AS-20211214161817 and #28-AS-20210820151018 for additional information.
• The allegation of “Staff are not providing residents with mail in a timely manner” was previously investigated and addressed by LPA Luis Mora on 10/12/21, Control #28-AS-20211004094822. The finding was delivered as Unsubstantiated. Please refer to Control #28-AS-20211004094822 for additional information.
An exit interview was conducted and a copy of this report was provided to the Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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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