198603183-6-8-2021-28-AS-MVAO-C49NVL-20210623104807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 06/08/2021
Date Signed: 06/08/2021 03:02:18 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
11/12/2020 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201112161242

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: 95	DATE:	06/08/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Dennise Torres		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff mismanaged residents medication.
Staff not providing adequate food service.
Staff not keeping facility free from pests.
Facility laundry room is dirty.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above allegations. LPA met with Assistant Administrator Dennise Torres and explained the reason for the visit.

The investigation consisted of the following: during the initial televisit conducted on 11/19/20, LPA interviewed the Assistant Administrator and conducted a virtual tour of the facility which included common areas, both laundry rooms and kitchen area. During today's visit, LPA interviewed the Assistant Administrator, Administrator, Staff #1 - Staff #5 and Resident #1 - Resident #9. LPA once again toured the common areas which included the laundry room and kitchen area.

The investigation revealed the following: in regards to the allegation "staff mismanaged residents medication", it is alleged that Staff #1 (S1) is administering incorrect medication to residents. No other details provided.

(CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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-20201112161242

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: 06/08/2021

NARRATIVE

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During today's visit, LPA reviewed a random sample of medications and observed medications to be documented properly and given as prescribed. Interviews conducted with staff members, including S1 revealed that medications are given as per doctors orders. Interviews conducted with residents revealed that they are provided with their medications as prescribed. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "staff not providing adequate food service" it is alleged that the facility’s milk is spoiled and the chicken is undercooked. No other details provided. During virtual tour conducted on 11/19/20, LPA toured the kitchen and observed the milk and chicken in the fridge. Milk and chicken observed was not expired. During today's visit, LPA once again toured the kitchen and observed the milk and chicken in the refrigerator. Food items in the refrigerator were not expired. Facility keeps logs to monitor food temperature and fridge and freezer temperatures. Interviews conducted with staff members revealed that food and milk are fresh and usually delivered twice a week or as needed. Interviews conducted with residents revealed that they have not been served with expired milk and have not noticed undercooked chicken in their meals. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "staff not keeping facility free from pests", it is alleged that there are cockroaches and black widow spiders at the facility. No other details provided. During virtual tour conducted on 11/19/20, LPA toured the common areas of the facility and did not observe any insects in the facility. During today's visit, LPA once again toured the facility and did not observe any pests and/or insects. Interviews conducted with staff members revealed that preventive spraying and/or treatment is done every 2 weeks. Assistant Administrator provided LPA with pest control invoices for the last 3 months. 3 out of the 9 residents interviewed indicated that they have seen a few insects such as mosquitos or water bugs in the facility, however they do not consider it to be an issue. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "facility laundry room is dirty", it is alleged that the laundry room is dirty. No other details provided. During virtual tour conducted on 11/19/20, LPA toured both the resident laundry room and staff laundry room and did not observe either laundry room to be dirty. During today's visit, LPA once again toured both laundry rooms and did not observe them to be dirty.

(CONTINUED ON 9099C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20201112161242

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: 06/08/2021

NARRATIVE

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Interviews conducted with staff members revealed that both laundry rooms are cleaned several times throughout the day. Only 1 out the 9 residents interviewed revealed that he uses the laundry room and indicated that the laundry room is clean. Therefore there was insufficient evidence to corroborate with this 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.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

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