198603183-8-27-2021-28-AS-FFIS-C9T7QR-20211217205223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 08/27/2021
Date Signed: 08/27/2021 11:50:08 AM

Unsubstantiated

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
08/20/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210820151018

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:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dennise Torres; Assistant Administrator		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Facility staff speak inappropriately to resident.
Facility staff are not assisting resident with transportation to medical appointments.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced complaint visit regarding the above stated allegations. LPA met with Med-Tech Lilly Centeno and explained the reason for the visit. Assistant Administrator Dennise Torres arrived shortly thereafter.

The investigation consisted of the following: during today's visit, LPA obtained copies of Resident & Staff Rosters. LPA also reviewed Resident #1 (R1) file and obtained copies of Physician's Report, FACE Sheet, and Needs & Services Appraisal. LPA also conducted interviews with Resident #1 - Resident #11, and Staff #1 - Staff #4.

The investigation revealed the following: in regards to the allegation "facility staff speak inappropriately to resident", it is alleged that facility staff "criticize" R1. LPA attempted to obtain additional information from R1, however R1 refused to provide any information. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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-20210820151018

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: 08/27/2021

NARRATIVE

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Interviews conducted with residents revealed that facility staff members treat them with respect and dignity. Residents interviewed revealed that facility staff do not speak to them inappropriately. Interviews with staff members revealed that they do not speak inappropriately to any of the residents. Therefore there was insufficient evidence to corroborate with this allegation.

In regards to the allegation "facility staff are not assisting resident with transportation to medical appointments", it is alleged that facility staff canceled R1's rides to her doctors appointments. LPA attempted to obtain additional information from R1, however R1 refused to provide any information. Interviews conducted with facility staff revealed that R1 schedules her own transportation to her doctors appointments. Residents will usually use insurance transportation services for their medical appointments, but if residents miss their transportation facility will arrange transportation services for residents via Uber/Lyft for residents at no extra cost. Assistant Administrator provided Uber receipt dated 08/19/21 for R1 showing transportation services to R1's medical appointment. Interviews conducted with staff members revealed that they have not canceled transportation services for any residents and will assist residents with arrangement of transportation services to medical appointments as needed. Interviews conducted with residents revealed that facility staff will assist them with arranging transportation to medical appointments. LPA also observed facility keeps a "Transportation Log" for the residents who have received assistance from the facility with transportation services to their medical appointments. 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.

NAME OF LICENSING PROGRAM MANAGER: Rebecca Orendain
NAME OF LICENSING PROGRAM ANALYST: David Sicairos
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

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