198603183-9-17-2024-28-AS-WSHO-D9LU9N-20240930152324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 09/17/2024
Date Signed: 09/17/2024 02:14:48 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
09/12/2024 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20240912111744

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: 110	DATE:	09/17/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Claudia Cordoba		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff did not provide resident a copy of the admission agreement in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Wellness Director Claudia Cordoba. Assistant Administrator Dennise Torres arrived shortly after who assisted with the visit. Purpose of the visit was explained.

During this visit, LPA obtained a copy of the resident and staff rosters and reviewed Residents #1 (R1) fille and obtained relevant documentation. LPA also interviewed Staff #1 (S1) and Staff #2 (S2) and Resident #1 (R1) through Resident #11 (R11) .

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

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-20240912111744

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: 09/17/2024

NARRATIVE

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Allegation: Staff did not provide resident a copy of the admission agreement in a timely manner. It was alleged that R1 never received a copy of admission agreement and R1 was not aware of any fees R1 would be responsible for at the time of admission.

Record review confirm that R1 was admitted to the facility on 06/10/2024. Admission Agreement was signed by R1 with the adjusted monthly rate $823.07 (Basic service rate was $1398.07). Interviewed R1 stated that it was misunderstanding about the fees, and they have a copy of Admission Agreement. R1 stated that they agree to the terms of the admission agreement and signed it on 06/10/24, don't have any concerns about this matter. Residents interviewed were not able to corroborate the allegation. All interviewed residents stated that they or their responsible parties did receive copies of their admission agreement and other paperwork in a timely manner. Interviewed S1 and S2 denied the allegation. They stated that they provide copies of resident’s paperwork, including the Admission Agreement to R1 and other residents or their responsible parties in a timely manner, at the time of admission. Also, residents and their responsible parties were informed that copies of resident’s chart could be provided to their request. S1 and S2 stated R1 was interviewed at Rehabilitation Center from where R1 was transferred and was informed about payment obligations. They stated that facility decided to charge less for the rent to help R1 with their finances.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted and a copy of this report was provided to Assistant Administrator Dennise Torres.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024

LIC9099 (FAS) - (06/04)

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