198603183-2-2-2024-28-AS-LHIS-D2XQMH-20240301111733

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 02/01/2024
Date Signed: 02/02/2024 03:44:41 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
01/26/2024 and conducted by Evaluator Nicol Wesley

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240126110717

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: 112	DATE:	02/01/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Dennise Torres		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff is not providing medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicol Wesley conducted an unannounced 10 day complaint visit at the facilty and met with Dennise Torres to explain the purpose for todays visit.

Investigation consisted of the following: LPA requested Resident Roster, Staff Roster, visited the medication room, interviewed residents, and interviewed staff and gathered paperwork according to the complaint.

Regarding allegation: Facility staff is not providing medication as prescribed. During the investigation LPA Wesley interviewed 9 out of 10 residents who said they receive their medication on time, and 9 out of10 residents indicated, their medication is given according to the doctors orders. LPA reviewed medication and computerized medication logs, review physician orders, interviewed medication staff, including LVN Claudia Cordoba.

Investigation continued on LIC 9099C,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

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-20240126110717

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: 02/01/2024

NARRATIVE

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Investigation revealed the following, It appears that resident #1, has refused medication since August 1 2023, and indicated that he refuses to receive medication from LVN Cordoba, and refusing meals. Based on the interviews conducted with staff, clients, review of client files and facility records, there was not enough supportive evidence to concur with the reported allegation. 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.

A copy of this report was given to Administrator Dennise Torres, during the exit interview.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Nicol Wesley	TELEPHONE: (323) 981-3975
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024

LIC9099 (FAS) - (06/04)

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