198603183-9-1-2021-28-AS-LHIS-C6WT5N-20210916142548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 09/01/2021
Date Signed: 09/01/2021 01:17:12 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
08/26/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210826112627

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: 102	DATE:	09/01/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Dennise Torres, Asst. Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff handled resident in a rough manner

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Angelica Rea and Jewel Baptiste conducted an unannounced complaint visit in response to the above allegation. LPA met with Assistant Administrator, Dennise Torres who assisted with today's visit.

Regarding the allegation that Staff handled resident in a rough manner, the investigation consisted of interviews with Assistant Administrator, Staff #1 - #3, and interviews with Residents #1 - #10. Assistant Administrator and Staff interviewed denied the allegation. They stated that they have not observed any staff handle residents in a rough manner. Staff indicated that they have been trained on how to treat the residents. Staff stated if they observed any staff treat residents in a rough manner, they would report it immediately. Residents interviewed were unable to corroborate the allegation. 10 out of 10 residents stated that they have not observed staff handle resident(s) in a rough manner. Residents stated that staff treat them well.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

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-20210826112627

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: 09/01/2021

NARRATIVE

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Based on LPA's observations and interviews, investigation revealed: 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.

No Deficiencies cited under California Code of Regulations Title 22. Exit interview conducted, and a copy of report was provided to Assistant Administrator, Dennise Torres.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021

LIC9099 (FAS) - (06/04)

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