198603183-6-14-2023-28-AS-TVAO-CWPL9B-20231017083311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 06/14/2023
Date Signed: 06/14/2023 12:52:22 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

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:	06/14/2023
		UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Case Manager / Eliana Lopez Administrator / Dennise Torres		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident fell while in care

Facility is forcing resident to use their physicians and dentist

Staff are not providing a comfortable environment for residents

Staff are not providing adequate food service for resident

Resident is scared to leave the facility due to facility staff not letting Resident back in

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced follow up visit to this facility to deliver findings on the above-mentioned allegations. Upon arriving at the facility, LPA met with Case Manager / Eliana Lopez and was later joined by the Administrator / Dennise Torres who assisted with the visit. LPA explained the purpose of today's visit.

LPA Katrdzhyan conducted prior visits to this facility on 10/6/22 and 6/13/23, in reference to the allegations listed above. During the course of the investigation, interviews were conducted of various persons to include the Administrator, Wellness Director / Claudia Cordoba, Residents 2 - 6 (R2 - R6) and Staff members 1 and 2 (S1 and S2). LPA made an attempt to interview Resident 7 (R7) but R7 refused. LPA was unable to interview Resident 1 (R1) because R1 expired on 1/4/22. LPA toured the facility kitchen, main hallway and nearby activity rooms. Also, copies of the following documents were obtained and reviewed in reference to R1;
• Identification and Emergency Information • Resident Appraisal • Physician's Report • Medical Reports

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: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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-20220927150112

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: 06/14/2023

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

• Discharge Instructions from Emanate Health Queen of the Valley Hospital dated 1/3/22 • Facility Menu
• Alternate food slip

The investigation revealed the following;

Allegation: Resident fell while in care.
Based on interviews conducted and records reviewed, LPA discovered that R1 sustained unwitnessed and unforeseen falls. The fall incidents occurred during period 1/2/22 – 1/4/22. R1 had an unwitnessed fall on 1/2/22 in the dining room. The paramedics were called and arrived but R1 refused to go to the hospital. On 1/3/22, R1’s sister was contacted by staff to help convince R1 to go to the hospital for further evaluation, at which time R1 agreed. An ambulance was called and R1 was transported to Emanate Health Queen of the Valley Hospital (EHQVH). R1 was evaluated at EHQVH and diagnosed with a supracondylar fracture of the humerus (left elbow). R1 was released shortly after in stable condition and asked to follow up with primary care physician (PCP) in 1 -2 days. R1 sustained a second fall in her room on 1/3/22, at around 8:30pm. No visible injuries were noted by staff. R1 refused to go to the hospital. R1 sustained a third fall in her room on 1/4/22, at 6:30am. No visible injuries were noted by staff and R1 refused to be sent to the hospital. R1 expired on 1/4/22, at 8:40am. According to the Death Certificate, the cause of death was noted as Cardiopulmonary Arrest and Chronic Obstructive Pulmonary Disease (COPD). Per the Administrator, the family of R1 and R1’s PCP were notified after each fall. After reviewing the file of R1, it was noted that R1 was ambulatory and did not require assistance with her activities of daily living. Based on interviews conducted and records reviewed, R1 was not a fall risk resident and did not have a history of prior falls.
The facility provided proper treatment to R1 after her falls; observation and medical attention by staff. Law Enforcement was on scene at the time of R1’s passing but no further action was taken. Based on the investigation conducted, no evidence of Neglect/Lack of Supervision was found.

Allegation: Facility is forcing resident to use their physicians and dentist.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the allegation. Staff and residents interviewed stated that residents are not forced by staff to use the in-house facility physicians and dentist. Staff offer residents to use the in-house physicians and dentist in order to make it easier and convenient for the residents, but residents are never forced. Residents have the option of using an outside physician and dentist if they wish. According to the Administrator, there are many residents at the facility who use outside physicians and dentists. Based on interviews conducted, there is insufficient

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20220927150112

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: 06/14/2023

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

evidence to support this allegation to be true.

Allegation: Staff are not providing a comfortable environment for residents. The details of this allegation states that facility staff leave the air condition on all day and night and it’s freezing.
During the visit conducted on 6/13/23, at 11am, LPA toured the main hallway area and the nearby activity rooms and measured the temperature inside the facility at 75 degrees F. Staff and residents interviewed denied staff having the air condition on all day and night making it uncomfortable/freezing for the residents. Residents interviewed stated that the facility temperature is comfortable during the summer time and winter time. Based on LPA’s observation and interviews conducted, there is insufficient evidence to support this allegation to be true.

Allegation: Staff are not providing adequate food service for resident.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the allegation. Staff and residents interviewed denied staff not providing adequate food service for residents and residents having to wait 15 minutes or more for items requested during meals. Residents stated that facility staff are nice about providing room service. Staff and residents stated that the meals served during breakfast, lunch and dinner are of variety and residents are not rushed during meals. LPA verified on the facility food menu that the meals served daily are not the same and there is a variety during each serving. According to the Administrator, everything listed on the menu is approved by a dietician. In the event, a resident refuses to eat what is listed on the daily menu, there is a substitute which consists of a bologna/ham & cheese sandwich, peanut butter and jelly sandwich, grilled cheese, quesadilla, salad, fruit plate and cottage cheese. The kitchen is also open for coffee, water, juice and ice. During the visit conducted on 6/13/23, LPA toured the facility kitchen and observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed meats, fruits, vegetables, eggs, juice, milk and snacks at the facility. Based on LPA's observation, interviews conducted and records reviewed, there is insufficient evidence to support this allegation to be true.

Allegation: Resident is scared to leave the facility due to facility staff not letting Resident back in.
Based on interviews conducted, the statements obtained were inconsistent and did not corroborate with the allegation. Staff and residents interviewed denied residents being scared to leave the facility due to facility staff not letting residents back inside the facility. The facility has a ring system which notifies staff when someone is at the front door and statements obtained from residents stated that there is always a staff person available to open the door and let residents back inside the facility. Based on interviews conducted, there is

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20220927150112

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: 06/14/2023

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	insufficient evidence to support this allegation to be true. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Joe Katrdzhyan	TELEPHONE: (323) 981-3968
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4