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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603183
Report Date: 07/14/2025
Date Signed: 07/14/2025 12:48:33 PM

Document Has Been Signed on 07/14/2025 12:48 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 LIVINGFACILITY NUMBER:
198603183
ADMINISTRATOR/
DIRECTOR:		SAMUEL DEUTSCHFACILITY TYPE:
740
ADDRESS:824 W. CAMERON AVETELEPHONE:
(626) 962-3511
CITY:W. COVINASTATE: CAZIP CODE:
91790
CAPACITY: 136CENSUS: 117DATE:
07/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Dennise Torres, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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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, activity room, two laundry rooms, storage rooms, 3 offices, Med Room, library 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 detergent locked in the laundry rooms and inaccessible to residents. Sharps are locked in the kitchen and inaccessible to residents. 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 111.5 - 117.1 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.

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NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/14/2025
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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 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 07/01/25.


Exit interview conducted and a copy of the report was provided to Assistant Administrator.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
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