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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603183
Report Date: 10/06/2022
Date Signed: 10/06/2022 03:35:31 PM

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
12/03/2020 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201203083044
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: 126DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Dennise TorresTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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9
Licensee did not report change of condition to responsible party
Staff verbally abused resident
Licensee did not accommodate resident's privacy during telephone call
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced subsequent visit regarding the above stated allegations. LPA met with Dennise Torres and explained the reason for the visit.

Initial visit on 12/8/20 consisted of the following: LPA obtained copies of Staff & Resident Rosters. LPA collected documents from Resident #1 (R1) file. LPA interviewed Staff #1-#2 (S1-S2).

On todays visit, LPA interviewed Staff #3-#5 (S3-S5) and residents #2-#12 (R2-R12). R1 is no longer in the facility and was unable to be interviewed. The investigation revealed the following:

In regards to the allegation "Licensee did not report change of condition to responsible party", it is alleged that R1 had a fall and was later hospitalized, but the facility did not report to R1's responsible party. (5) of (5) staff interviewed denied the allegation. (11) of (11) residents interviewed could not corroborate the allegation.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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 2
Control Number 28-AS-20201203083044
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: 10/06/2022
NARRATIVE
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Interviews show that R1 was taken to the hospital in November 2020 and did not return to the facility. According to interviews, the last update was that the resident was transferred to a skilled nursing facility. Interviews do not show that R1 had a witnessed fall or that R1 went to the hospital because of a fall. Review of incident reports shows that R1 was taken to the hospital on 11/27/20 for weakness and confusion. Documents do not show R1 had a fall in the facility. Review of documents does not show that R1 has a responsible party on file as they are self responsible. Based on interviews and file review conducted, there was not enough supportive evidence to concur with the reported allegation. 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.

In regards to the allegation "Staff verbally abused resident", it is alleged that S3 yelled at R1 while R1 was on the phone. (5) of (5) staff interviewed denied the allegation. (11) of (11) Residents interviewed could not corroborate the allegation. Interviews do not show that S3 yelled at R1. LPA was not provided with a date on when alleged incident would have occurred. LPA was unable to interview R1 to verify information. Based on interviews conducted, there was not enough supportive evidence to concur with the reported allegation. 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.

In regards to the allegation "Licensee did not accommodate resident's privacy during telephone call ", it is alleged that S3 and S4 did not allow R1 privacy while R1 used the phone and took R1's phone away. (5) of (5) staff interviewed denied the allegation. (11) of (11) residents interviewed could not corroborate the allegation. Interviews do not show that staff invaded R1's privacy on the phone. S4 denies ever taking R1's phone. LPA was not provided with a date on when alleged incident would have occurred or further information. LPA was unable to interview R1 to verify information. Based on interviews conducted, there was not enough supportive evidence to concur with the reported allegation. 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.

Exit interview was conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2