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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 10/26/2021
Date Signed: 10/26/2021 03:20:51 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
12/21/2020 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20201221091943
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: 9DATE:
10/26/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Assistant Administrator, Laura HernandezTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff pushed resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint visit to investigate the allegation listed above. LPA met with Assistant Administrator, Laura Hernandez and explained the reason for todays visit.

The investigation consisted of the following: On 12/29/2020, LPA Almaraz conducted interviews with Administrator, Trupti Mody which will be referred as (Staff #5) and Hernandez (Staff #6). LPA also interviewed Staff #1 and #3 telephonically and requested Staff and Resident Roster, and Staff #1-4 files. On 10/26/2021, LPA interviewed Staff #2, Staff #4, Staff #7-8, reinterviewed Staff #6 and requested Staff #9's file along with training records for all staff. LPA also interviewed Residents #1-4 and was unable to interview Resident #5. Resident #1 was not able to answer LPA's questions due to the residents limitations.

The investigation revealed the following: It was alleged a former staff had pushed a former resident at the facility. (Continued on an 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: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
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 2
Control Number 28-AS-20201221091943
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: 10/26/2021
NARRATIVE
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Based on interviews conducted, the former staff member who allegedly pushed the resident gave the impression to other caregivers that the staff member disliked Resident #5. Interviews with staff stated that although they got that impression they never witness the staff push the resident or any other resident. Staff members also stated they have never witness any of the other staff pushing or hitting any of the residents.
Staff #8 stated there was an incident that occurred around December 2020 between Staff #9 and Resident #5 where the mother of Resident #5 complained about witnessing Staff #9 pushing Resident #5. Staff #8 said the staff did not witness the incident but the staff recalls it was about Staff #9 pushing Resident #5. Per Staff #8, the mother informed Staff #6, who was the Administrator at the time and was aware of it. Staff #6 denies of any report made in regards to Resident #5 and Staff #9. On 10/26/2021, LPA re-interviewed Staff #6, who stated staff recalls the mother of Resident #5 complaining about Staff #9. Staff #6 stated staff does not remember if the mother said Staff #9 pushed the resident but recalls the mother saying screaming to Resident #5. Staff #6 stated there was a discussion with Staff #9 where the staff denied pushing the resident but had rather blocked the resident from entering the front building where the resident can leave the premises or interrupt the visitor exiting the building. Staff #9 denied to Staff #6 pushing the resident and stated to Staff #6 that the staff did not realize it was a family member of Resident #5. Per Staff #6, the residents are re-directed because they all have Dementia or Alzheimer's. LPA also conducted interviews with Residents #1-4. Three (3) out of the (4) residents stated they are happy at the facility and staff are nice. One (1) resident was unable to answer LPA's questions do to the residents limitations.

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. An exit interview was conducted with the Assistant Administrator and a hard copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2