197608323-9-21-2021-28-AS-LHIS-C7HQ98-20211005115755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608323
Report Date: 09/21/2021
Date Signed: 09/21/2021 01:52:00 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
12/27/2019 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191227113251

FACILITY NAME:	MOUNTAIN VIEW TERRACE, LLC		FACILITY NUMBER:	197608323
ADMINISTRATOR:	LINDA MCINTOSH		FACILITY TYPE:	740
ADDRESS:	603 TOCINO DRIVE		TELEPHONE:	(626) 205-3211
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	6	CENSUS: 5	DATE:	09/21/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Linda McIntosh		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Staff failed to meet residents needs
Lack of supervision resulting in resident sustaining multiple falls
Facility is over medicating resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Administrator, Linda McIntosh who assisted with today's visit.

Regarding the allegation that staff failed to meet resident #1's needs, the investigation consisted of Interview(s) with Administrator, Staff, and review of Resident #1's file. The investigation revealed that resident #1 lived at the facility from 3/29/19 - 12/12/19. Resident #1 was diagnosed with hammer toe on her left foot, which caused her to develop a wound on her left second toe. Administrator stated that resident #1 was receiving home health services for the wound twice per week. Administrator was providing wound care for resident #1 on the days that home health did not come to the facility. LPA obtained copies of Home Health notes. Resident #1 was taken to hospital twice on 11/7/19, and on 12/12/19 for observation of left toe wound. LPA reviewed hospital notes, and did not observe that resident #1 was diagnosed with sepsis or dehydration as alleged.. LPA was unable to interview Resident #1, as resident no longer lives at the facility.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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-20191227113251

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: MOUNTAIN VIEW TERRACE, LLC	FACILITY NUMBER: 197608323
	VISIT DATE: 09/21/2021

NARRATIVE

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Regarding the allegation that lack of supervision resulting in resident #1 sustaining multiple falls, the investigation consisted of Interview(s) with Administrator, Staff, and review of Resident #1's file. The investigation revealed that resident #1 was found on floor in her room by night shift staff on 12/4/19. However, Administrator stated that it was not confirmed that resident #1 fell. Resident #1 was observed to be on her knees and holding onto the bed rails by staff. Resident #1 was unable to state what happened. Resident #1 was assessed, and was not observed to have any scratches or bruising to body. Facility submitted a Special Incident Report as required. Administrator and Staff interviewed stated that Resident #1 did not sustain any falls while residing at the facility. LPA was unable to interview Resident #1, as resident no longer lives at the facility.

Regarding the allegation that Facility is over medicating resident #1, the investigation consisted of Interview(s) with Administrator, Staff, and review of Resident #1's file, including Medication Administration Record(s). The investigation revealed that the facility was administering medications as prescribed by Resident #1 physician(s). Administrator and Staff interviewed denied that facility was over medicating Resident #1. LPA was unable to interview Resident #1, as resident no longer lives at the facility.

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 Administrator, Linda McIntosh.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC9099 (FAS) - (06/04)

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