198603183-3-30-2021-28-AS-MVAO-C2ASEU-20210421134920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 03/30/2021
Date Signed: 03/30/2021 01:21:07 PM

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
03/25/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210325162440

FACILITY NAME:	COUNTRY VIEW ASSISTED LIVING		FACILITY NUMBER:	198603183
ADMINISTRATOR:	ALBA, HELEN		FACILITY TYPE:	740
ADDRESS:	824 W. CAMERON AVE		TELEPHONE:	(626) 962-3511
CITY:	W. COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY:	136	CENSUS: 97	DATE:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Denise Torres, assistant administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility did not safeguard resident's belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo initiated a complaint investigation for the allegation 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 Denise Torres, assistant administrator.

The investigation consisted of the following: Conducted telephone interview with assistant administrator and staff from Maywood Healthcare Center. Also conducted a virtual tour of the facility including Resident #1's (R1) room.

The investigation revealed the following: It's alleged facility has not released R1's personal belongings to the Skilled Nursing Facility (SNF) R1 is currently residing in because facility has lost the belongings. Assistant administrator is aware of the situation and confirmed the belongings were not ready when the SNF staff was there to pick them up, but denied that the belongings were lost. Assistant administrator indicated the belongings are now ready for pick-up. Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

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-20210325162440

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: 03/30/2021

NARRATIVE

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A virtual tour was conducted of R1's room. The closet was empty and there were 4 bags, 1 box and 1 small dresser that belongs to R1. The SNF staff interviewed confirmed they have gone to the facility approximately 2 times to drop off patients and pick-up R1's belongings. Each time SNF staff were told the items were not ready, but did not know if the belongings had been lost. Assistant administrator indicated she contacted the SNF today and the SNF will be picking up the belongings this afternoon. Based on the information obtained, R1's belongings have not gone missing and are now ready for pick-up.

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.

A telephonic exit interview was conducted with assistant administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

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