198603183-5-9-2024-28-AS-WSHO-D5VRT8-20240603131751

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 05/09/2024
Date Signed: 05/09/2024 03:14:34 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
04/30/2024 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20240430113936

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: 111	DATE:	05/09/2024
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Claudia Cordoba		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff did not provide medical records as requested by resident.
Staff changed resident's medical insurance without the resident's consent.

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 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:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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 3

Control Number 28-AS-20240430113936

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: 05/09/2024

NARRATIVE

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Allegations: Staff did not provide medical records as requested by resident. It was alleged that R1's medical records have been erased between 9/1/22 through 11/1/22. No records of hospitalization, medical procedure, nursing facility stay or any medication for that time period can be found.
Interviewed staff denied the allegation. They stated that they always provide the medical records to the residents or Representative parties / conservator upon their request. S1 stated that information will be provided to resident /conservator immediately by their request. S2 stated that they provide medical records requested by residents for any hospital discharge, doctor's visits at all times without questions. They did not deny the access to medical records to any of the residents. S1 and S2 stated that it is residents right to be aware of any changes, any new diagnosis, or treatments that they might have. They stated that they provided R1's medical records that they have in the facility files. LPA obtained and reviewed the copy of R1's medical records and SIRs dated 09/01/22, 09/06/22, 09/07/22 and 09/10/22 and observed that R1 was hospitalized on 09/01/22 and left the hospital AMA (against medical advice) on 09/06/22. At the same day R1 was seen by the Facility doctor for an assessment after R1 left the hospital AMA. Home Health was requested because of R1's health condition. (Copies of Referral and doctor's order provided to LPA). On 09/07/22 R1 was transitioned to West Haven Nursing Home, and R1 left the Nursing Home again AMA. With no discharge papers, no plan, no indication. At the time of visit S1 provided copies of the R1's medical records and handle it to R1. Residents interviewed revealed that 10 out of 11 residents could not corroborate with the allegation.

Allegation: Staff changed resident's medical insurance without the resident's consent. It was alleged that R1 Blue Shield insurance was cancelled on 8/31/22 without R1's permission to Medical.Net by a doctor at the facility, and R1's account was restricted to R1.
Interviewed staff denied the allegation. They stated that Facility staff / doctors do not change insurances without the resident's / conservator's consent. They follow the mandated protocols and rules that protect resident's rights. They stated that facility staff / doctors didn't change R1's medical insurance with or without R1's consent. At the time of visit S1 assisted R1 in contacting Medicare and Blue Shield health plan. R1 spoke to multiply representative for over one hour and representatives informed that R1's insurance plan could only be canceled or switched with R1's consent.

Continue 9099C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240430113936

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: 05/09/2024

NARRATIVE

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They also told R1 that sometimes insurance plans find them not eligible and that they will switch the plan and inform them of the change. S1 indicated that happened with R3 before and S1 was able to assist with correcting the change. Insurance representatives found no information on any party canceling R1 plan on R1's behalf and R1 was never without coverage during any period. LPA was present at the time of phone conversation, Unfortunately, R1 not want to believe what the representatives are telling R1 and insists that a doctor changed their insurance plan. Residents interviewed revealed that 10 out of 11 residents could not corroborate with the allegation.

Based on the interviews conducted with staff, residents, review of client file and facility records, there was not enough supportive evidence to concur with the reported allegations. 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 with Assistant Administrator Dennise Torres and the copy of this report was . provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC9099 (FAS) - (06/04)

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