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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 07/27/2021
Date Signed: 07/27/2021 05:22:04 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
07/21/2021 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20210721121852
FACILITY NAME:MOUNTAIN VIEW CENTERFACILITY NUMBER:
197801605
ADMINISTRATOR:LAURA HERNANDEZFACILITY TYPE:
740
ADDRESS:715 WEST BASELINE ROADTELEPHONE:
(909) 626-6633
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:40CENSUS: 12DATE:
07/27/2021
UNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Lee Stotts, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility failed to provide resident's medical records to authorized POA.
Facility Staff failed to seek proper medical attention for UTI.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA's) Linda Almaraz and Nina Galarza conducted a complaint visit to investigate the allegations listed above. LPA's met with Administrator, Lee Stotts and discussed the reason for todays visit.

The investigation consisted of the following: LPA's interviewed Administrator, Staff #1 and attempted to interview Staff #2 and 3 who were off. LPA's also interviewed Residents #1-4. LPA's requested copies of Staff and Resident Rosters, Resident #1's File and MAR logs, and reviewed medication.

The investigation revealed the following: It was alleged the facility failed to provide resident medical records for Resident #1. Interviews and records reviewed revealed the facility sent the residents Power of Attorney (POA) the medical records via email on 7/21/2021, at about 11:33AM. Records show the POA stated she did not receive the records and the Administrator re-sent the records at about 1:27PM. (continued on LIC-9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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 5
Control Number 28-AS-20210721121852
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 CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 07/27/2021
NARRATIVE
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Interviews revealed Resident #1 has a history of UTI and had recently developed a strong urine smell. Per interviews conducted, the doctor was contacted on 7/15/21 in regards to the urine smell. Facility provided a urine sample to the POA on 7/19/21 and the resident was diagnosed with a UTI on 7/25/21. Order for medication was placed with pharmacy and the medication was received today 7/27/21.

Based on LPA's interviews conducted and records reviewed, 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 above allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted with the Administrator and a hardcopy was provided.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/21/2021 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20210721121852

FACILITY NAME:MOUNTAIN VIEW CENTERFACILITY NUMBER:
197801605
ADMINISTRATOR:LAURA HERNANDEZFACILITY TYPE:
740
ADDRESS:715 WEST BASELINE ROADTELEPHONE:
(909) 626-6633
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:40CENSUS: 12DATE:
07/27/2021
UNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Lee Stotts, AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff failed to provide residents medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA's) Linda Almaraz and Nina Galarza conducted a complaint visit to investigate the allegation listed above. LPA's met with Administrator, Lee Stotts and discussed the reason for todays visit.

The investigation consisted of the following: LPA's interviewed Administrator, Staff #1 and attempted to interview Staff #2 and 3 who were off. LPA's also interviewed Residents #1-4. LPA's requested copies of Staff and Resident Rosters, Resident #1's File and MAR logs, and reviewed medication.

The investigation revealed the following: It was alleged the facility was not providing residents medication as prescribed. Based on records reviewed and interviews conducted. The facility initally had an order for 40mg of Furosemide and an additional 20mg PRN of Furosemide. Records revealed the resident was given the medication as prescribed for the month of June and the begining of July. On 7/20/21, the doctor ordered a prescription for 20mg of Furosemide. (Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210721121852
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 CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 07/27/2021
NARRATIVE
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Upon reviewing Medication Administration Log (MAR log), LPA observed the 20mg Furosemide for today 7/27/21 not administered and still packaged. The MAR log was signed off as administered but the medication was still packaged and not dispensed for 7/27/21. Records indicated the medication was supposed to be administered at 8AM. LPA's also noted the following discrepancies, Potassium and Setraline was administered at 8AM and not signed off.

The State of California, Department of Social Services, Community Care Licensing Division investigated the allegation "Staff failed to provide residents medications as prescribed", based on records reviewed and observation the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies cited under California Code of Regulations Title 22.

Exit interview was conducted with the Administration and a hard copy of the report and Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210721121852
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 CENTER
FACILITY NUMBER: 197801605
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2021
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, ....provided all of the following requirements are met:
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Administrator will have a pharmacy conduct training with all staff who administer medication.

Administrator will send material of subjects covered and sign in sheet of attendees by POC due date.
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(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidence by: Facility failed to provide Resident #1, Flurosemide 20mg on 7/27/21 at 8AM.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5