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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603183
Report Date: 07/16/2021
Date Signed: 07/16/2021 12:02:30 PM

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:ALBA, HELENFACILITY TYPE:
740
ADDRESS:824 W. CAMERON AVETELEPHONE:
(626) 962-3511
CITY:W. COVINASTATE: CAZIP CODE:
91790
CAPACITY:136CENSUS: 110DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Dennise Torres; Assistant AdministratorTIME COMPLETED:
12:16 PM
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Licensing Program Analysts (LPAs) David Sicairos and Luis Mora conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPAs met with Med-Tech Lilly Centeno and explained the reason for the visit. Assistant Administrator Dennise Torres arrived shortly thereafter. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

The following were observed/inspected:
  • LPAs 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 water temperature was tested in a random selection of resident bathrooms and measured between 112.1F - 119F. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is several carbon monoxide detectors throughout the hallways of the facility. There are several fire extinguisher located throughout the facility. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Cleaning supplies and toxins are locked in a storage room and are inaccessible to residents. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed.
  • (10) resident medications were reviewed at random. Medications are documented properly and given as prescribed.
  • Staff and Resident files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David SicairosTELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
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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