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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:55:04 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
12/16/2020 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20201216154032
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:
10/27/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Assistant Administrator, Laura HernandezTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident had unexplained injury
Staff did not notify authorized representative of residents injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Linda Almaraz conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Assistant Administrator, Laura Hernandez and explained the reason for todays visit.

The investigation consisted of the following: On 12/23/2020, LPA Almaraz conducted a virtual tour of the facility and residents. LPA conducted interviews with Mody, Singhvi and Staff #1-3 and requested a Staff and Resident Roster. On 10/26/2021, LPA Almaraz re-interviewed Staff #2-3 and interviewed Staff #4. LPA attempted to interview Resident #1 but the resident was no longer residing at the facility after being evicted on 12/10/2020. LPA requested Resident #1's file.

The investigation revealed the following: In regards to allegation, "Resident had unexplained injury" it was alleged Resident #1 received a black eye while living 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: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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-20201216154032
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: 10/27/2021
NARRATIVE
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Interviews with staff indicated the resident never had a black eye while residing at the facility. Interviews with staff revealed the resident was aggressive and would hit staff but did not have self injurious behaviors. Staff stated they never witnessed any staff hit the resident or hear about a staff hitting the resident or any other resident.

In regards to allegation "Staff did not notify authorized representative of residents injury" it was alleged the facility did not notify the responsible party of Resident #1 after sustaining a black eye at the facility. Interviews and records reviewed indicated the resident did not have a black eye, therefore the facility never contacted the responsible parties. A photograph was provided of the resident with the alleged black eye and LPA could not verify if it was the angle of the picture or a black eye.

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. 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: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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
12/16/2020 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20201216154032

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:
10/27/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Assistant Administrator, Laura HernandezTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff restrained 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 12/23/2020, LPA Almaraz conducted a virtual tour of the facility and residents. LPA conducted interviews with Mody, Singhvi and Staff #1-3 and requested a Staff and Resident Roster. On 10/26/2021, LPA Almaraz re-interviewed Staff #2-3 and interviewed Staff #4. LPA attempted to interview Resident #1 but the resident was no longer residing at the facility after being evicted on 12/10/2020. LPA requested Resident #1's file.

The investigation revealed the following: It was alledged the facility was putting Resident #1 in a Gerry Chair with its table as a form of restraint. (Continued on an LIC 9099C)
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: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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-20201216154032
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: 10/27/2021
NARRATIVE
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Interviews revealed the resident was put in the Gerry Chair with the table tray during meals and while caregivers put back the dishes back in the kitchen. Per interviews, the chair was used because it helped the resident stay more calm while eating. Interviews with staff also revealed the chair was used to elevate the residents legs when they were swollen. Staff stated they would put the resident in the chair for about an hour to help his legs.

Interviews and records showed the Gerry Chair did not belong to the resident and belong to other residents at the facility who were on hospice and had physicians orders for the chair. Community Care Licensing (CCL) never received a request/plan for approval prior to using the Gerry Chair. It is unclear how long the resident was left in the chair during the day or if it was used for other than meal time and leg elevation. LPA received a photograph of the resident in the Gerry chair with the table tray on, in what appeared to be a resident room at the facility. The table tray did not have any food on it. The residents file revealed the resident had Dementia and needed assistance with several of the residents Activities of Daily Living (ADL's). In an appraisal conducted on 7/3/2020, it indicated the resident was unable to communicate clearly. While living at the facility he became aggressive towards staff and the facility later determined they could not care for the resident due to the residents behaviors.

Based on records reviewed and interviews conducted, 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. Please see LIC 9099D


An exit interview was conducted with Assistant Administrator and copy of this report was provided. Appeal Rights provided.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20201216154032
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: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2021
Section Cited
CCR
87608(a)(3)
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87608 Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
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Administrator shall ensure that all residents using a Gerry chair have an order prior to using the chair and will keep a copy of the order on their file. The facility will also request and submit a plan if they plan on using the chair for residents who do not have an order in place. Administrator shall read section 87608 of the CCR and submit a written, signed statement
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(3) A written order from a physician indicating the need ...... The licensing agency shall be authorized to require other additional documentation.....
This requirement was not met as evidence by: Staff at the facility were putting resident #1 in a Gerry chair and using the table tray without prior approval or physcians order.
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stating they have read and understoof the section and will abide by it. POC due by 11/01/2021.
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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: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5