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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 10/29/2020
Date Signed: 11/04/2020 09:27:47 AM



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
09/04/2020 and conducted by Evaluator David Sicairos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200904145535
FACILITY NAME:COUNTRY VIEW ASSISTED LIVINGFACILITY NUMBER:
198603183
ADMINISTRATOR:ALBA, HELENFACILITY TYPE:
740
ADDRESS:824 W. CAMERON AVETELEPHONE:
(626) 962-3511
CITY:W. COVINASTATE: CAZIP CODE:
91790
CAPACITY:136CENSUS: 98DATE:
10/29/2020
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Samuel Deutsch & Dennise Torres TIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Some food in the refrigerator is going bad.
The roof is leaking.
The air conditioner is causing residents discomfort.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Sicairos initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Samuel Deutsch.

The investigation consisted of the following: During initial televisit conducted on 09/10/20, LPA conducted a virtual tour of the facility with the assistance of Med-Tech Veronica De Leon. LPA toured common areas and the kitchen area. LPA also requested copies of resident & staff rosters. During today's virtual visit, LPA once again toured the common areas and the kitchen area with the assistance of Assistant Administrator Dennise Torres. LPA also interviewed Resident #1 (R1) - Resident #8 (R8), and Staff #2 (S2) - Staff #4 (S4).

The investigation revealed the following: In regards to the allegation "some food in the refrigerator is going bad", it is alleged that there is no ice in the freezer and the milk is going bad. No other details provided.
(CONTINUED ON 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
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 2
Control Number 28-AS-20200904145535
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: 10/29/2020
NARRATIVE
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During virtual tours conducted on 09/10/20 and today, LPA observed the milk supply in the kitchen and did not see any expired milk in their inventory on either occasion. LPA also toured the pantry and did not observe any non-perishable foods that were expired. Interviews conducted with facility staff members all indicated that facility receives food delivery twice a week. All staff members interviewed denied serving expired milk to residents. Interviews conducted with residents all indicated that they do not have any problem with the milk that is served to them. Therefore, there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "the roof is leaking", there were no other details provided by the complainant. Location or time frame of the alleged leak was not provided. Interviews conducted with staff members all indicated that there haven't been any leaks. Administrator indicated brand new roof was installed a couple of years ago. Interviews conducted with residents all indicated that they were not aware of any leaks in the roof. Therefore, there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "the air conditioner is causing residents discomfort", it is alleged that the air conditioning is on 24/7 and residents are complaining about it being too cold. No other details provided. Interviews conducted with facility staff indicated that temperature is set at a comfortable temperature and is adjusted per resident requests. Administrator indicated that there are 13 units, 4 of which supply the common areas. There are also sensors in some of the other rooms to ensure even disbursement. If a resident feels its too hot or too cold, facility staff will close the resident's vent in their room at their request. Interviews conducted with residents all indicated that they are comfortable with the temperature at the facility. Therefore, there was insufficient evidence to corroborate with the allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file 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.

Telephonic exit interview held, and a copy of this report was emailed to Administrator for signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
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