198603183-6-25-2024-28-AS-NMAN-D6KUYV-20240625160034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603183
Report Date: 06/25/2024
Date Signed: 06/25/2024 04:00:41 PM

Document Has Been Signed on 06/25/2024 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 115	DATE:	06/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Dennise Torres		TIME COMPLETED:	04:00 PM

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	Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Assistant Administrator, Dennise Torres who assisted with visit. LPA explained the reason for the visit. The facility is licensed to serve 136 non-ambulatory residents ages 60 and over, of which 34 may be bedridden. There is a hospice waiver approved for 20 residents. The facility does not have a dementia care plan and does not accept any residents with dementia. There are some residents utilizing home health services but none on hospice. LPA and Assistant Administrator toured the facility which included a random sample of resident rooms along with the kitchen, dining room, both laundry rooms, storage room, and large movie room. The patio area is well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the patio area. Passageways and exits are free of obstruction. The common areas are clean and have the required furniture. The facility has 68 resident rooms with own bathrooms. LPA observed laundry room (next to the kitchen) door was open during visit. Laundry detergent and gallon of Bleach were observed and accessible to clients. Randomly chosen resident rooms were toured. Each room has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The water temperature was tested in a random selection of resident bathrooms. The hot water was between 112.6 - 118.2 degrees F which is within the required 105 - 120 degrees F. The kitchen was inspected. LPA observed sufficient food supplies of 2-day perishable and a 7 day of non-perishable food. All the appliances are clean and seem to be operating properly. The smoke detectors are interconnected and there are 2 operable carbon monoxide detectors. The facility has a signal system in place. Fire extinguishers were fully charged and operational. Continue 809C

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/25/2024 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed laundry room (next to the kitchen) door was open during visit. Laundry detergent and gallon of Bleach were observed and accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Laundry room was locked during the visit. POC cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/25/2024

NARRATIVE

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LPA observed the medications are centrally stored in the Med. room and inaccessible to clients. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. During today’s visit, LPA reviewed 6 resident medications and they are being administered as prescribed by the physician. The first aid kits were observed and found to be in compliance with the Title 22 Regulations.

LPA reviewed 5 personnel records and they have the required documents in file. LPA reviewed 5 resident records and they have the following documents in their files such as Admission Agreements, Identification & Emergency Information, Physician's Report with TB test results, Pre-admission appraisal, and Resident rights. Last Fire drill conducted on 04/23/24 (Southwest Fire Life Safety & Security LLC)

Per California Code of Regulations, Title 22, the deficiency observed is documented on the attached 809D.

Exit interview held. A copy of the report and appeal rights were provided to Assistant Administrator.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune Margaryan	TELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC809 (FAS) - (06/04)

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