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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 11/03/2021
Date Signed: 11/03/2021 04:21:52 PM

Substantiated


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
11/24/2020 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20201124163559
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: 10DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Assistant Administrator, Laura HernandezTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Lack of supervision resulting in residents sexually abusing other residents.
Facility has Insufficient staff to meet the residents' needs.
Residents are restrained.
Facility has scabies/C-diff outbreak.
Facility is in disrepair.
Residents are not provided with general hygiene supplies.
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) Jewel Baptiste and Linda Almaraz conducted a subsequent visit to conduct further investigation, file review and to deliver findings for the allegations listed above. Allegation #1 was referred to the Investigation Bureau and was investigated by Investigator Brian Slatic. All other allegations were investigated by LPA Almaraz. LPA's met with Assistant Administrator, Laura Hernandez and explained the reason for todays visit. On todays visit LPA's reviewed and collected documents for Residents #9-18.

The investigation consisted of the following: During the initial visit conducted on 11/25/2020, LPA Almaraz conducted a virtual tour of the living room, dining area, kitchen, outside patio, common areas and resident rooms. The kitchen was clean and had sufficient perishable and non-perishable foods. Resident rooms and common areas were appropriately furnished. LPA did not observe any visible signs of neglect, abuse or any obvious immediate health and safety threats. LPA requested copies of staff and resident roster along with files for Residents #1- 8 to be emailed or faxed to LPA by 11/25/2020. LPA also conducted an interview with the Administrator, Trupti Mody (Staff #16). (Conitnued 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: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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 10
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
11/24/2020 and conducted by Evaluator Linda M Almaraz
COMPLAINT CONTROL NUMBER: 28-AS-20201124163559

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:
11/03/2021
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Assistant Administrator, Laura HernandezTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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5
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8
9
Food service is inadequate.
Facility has inadequate laundry service.
INVESTIGATION FINDINGS:
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5
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Licensing Program Analyst's (LPA's) Jewel Baptiste and Linda Almaraz conducted a subsequent visit to conduct further investigation and deliver findings for the allegations listed above. LPA's met with Assistant Administrator and explained the reason for todays visit. On todays visit LPA's conducted additional file review and collected documents for Residents #9-18.

The investigation consisted of the following: During the initial visit conducted on 11/25/2020, LPA Almaraz conducted a virtual tour of the living room, dining area, kitchen, outside patio, common areas and resident rooms. The kitchen was clean and had sufficient perishable and non-perishable food. Resident rooms and common areas were properly furnished. LPA did not observe any signs of neglect, abuse or other immediate health and safety threats. LPA requested copies of staff and resident roster along with files for Residents #1- 8 to be emailed or faxed to LPA by 11/25/2020 and conducted an interview with the Administrator, Trupti Mody (Staff #16). (Conitnued 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: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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 10
Control Number 28-AS-20201124163559
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: 11/03/2021
NARRATIVE
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LPA interviewed current and former staff #1-15 and #17-18 along with Witness #19 telephonically on the following dates; 12/29/2020, 2/9/2021, 2/11/21, 2/12/21, 3/16/21, 3/23/21, 4/6/21 and 4/16/21. On 11/2/2021, LPA requested copies of additional residents records.

The investigation revealed the following: In regards to allegation,"Food service is inadequate," LPA interviewed staff in regards to meals served. (12) out of (18) staff members indicated they never seen any issues with the food the facility served and they quantity was enough. They stated the quality was also good and never heard of the facility running out of food. Staff indicated the residents had (3) meals a day and (2) snacks.

In regards to allegation, "Facility has inadequate laundry service," based on interviews conducted (12) out of (18) interviews conducted stated they never had an issue with the laundry being done for the residents and never heard of the facility running out of laundry soap. Per interviews, the residents had their clothes washed by the laundry person and would get done.

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, Laura Hernandez and Caregiver, Elvira Cortez 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: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 28-AS-20201124163559
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: 11/03/2021
NARRATIVE
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 current and former staff #1-15 and #17-18 along with Witness #19 telephonically on the following dates; 12/29/2020, 2/9/2021, 2/11/21, 2/12/21, 3/16/21, 3/23/21, 4/6/21 and 4/16/21. On 11/3/2021, LPA requested additional copies of residents records.

The investigation for allegation #1 was referred to the Investigation Bureau and was investigated solely by Investigator Brian Slatic. He conducted interviews with current and former staff, family members, and also obtained relevant resident records.

The investigation revealed the following: In regards to allegation: Lack of supervision resulting in resident sexually abusing other residents - During the course of the investigation, the investigator obtained information from individuals who personally witnessed many of the alleged actions and behaviors of Resident #9. Former staff members report seeing Resident #9 touch, fondle and rub female clients on their breasts and vaginal areas. Resident #9 was also found in another residents room, while the other resident had their pants down. Resident #9 was found in the bed of a female resident and caught taking a female dementia resident to the back area of the facility. Resident #9 also attempted to sexually assault a female resident while under the influence of drugs. Multiple staff informed Staff #1, who was the Administrator at the time of these incidents. However, no substantive action appeared to have been taken by Staff #1 or the Licensee to stop Resident #9's behaviors. The residents continued to be victimized by Resident #9. There is also no evidence that any of these incidents were reported to Community Care Licensing (CCL) or cross reported to other agencies.

In regards to allegation: Facility has insufficient staff to meet the residents' needs - several former and current staff stated that at some point last year there wasn't sufficient staff at the facility. Staff members revealed that sometimes they did not have help for transferring residents to their beds or up from their beds who required a 2-3 person assistance to transfer. Staff also stated sometimes during the night shift there was only one (1) staff member from the hours of 11PM- to about 5AM because the second staff member would call off and the facility would not get coverage. Per interviews, it happened very often and the one (1) caregiver could not finish their rounds. Caregivers indicated sometimes they could not complete diaper changes at night when it was just one (1) caregiver. Some of the things caregivers stated they could not complete due to staffing issues was showers, repositioning and grooming. They also stated that breakfast was rushed and the residents were pressured to eat quickly so they can complete other duties. Per staff interviews, this was brought up to the attention of Staff #1 and the Licensee and nothing was ever done. (Continued on an LIC 9099C)
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 28-AS-20201124163559
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: 11/03/2021
NARRATIVE
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 In one instance, a caregiver was told that CCL did not mandate a staff to resident ratio and could have one (1) caregiver only for all the residents. Per interviews conducted, the total resident census at the time was between 25 -30 residents. LPA received photographs of residents left soiled on the floor, and bed rails not in place with bed sheets falling off the beds. Another picture received was of a resident naked from the waist down in a fetal position and their bed soiled with feces.

In regards to allegation: Residents are restrained - it was alleged the facility was tying the residents with bedsheets to their wheels chairs and using Gerry chairs with a table tray on residents who did not have an order for the chair, and gait belts to keep the residents in place. Interviews conducted revealed a number of residents were tied with bedsheets to their wheelchairs in order to prevent them from falling off their wheelchair and to help caregivers complete their duties with other residents. Caregivers interviewed stated that they would have them tied from the waist to the wheelchair and sometimes from the chest to prevent them from falling and injuring themselves. Several current and former staff indicated that Resident #5 was put in Gerry chair with the table tray because the resident was very aggressive. LPA also received a picture of the resident in the Gerry chair with the tray on top of the resident. No physicians orders were observed in resident's file for the Gerry chair. LPA received pictures of another resident tied with a light blue/gray bedsheet around the stomach and chest area and the knot at the back of the wheel chair.

In regards to allegation: Facility has scabies/C-diff outbreak- it was alleged a few residents had scabies and C-diff at the facility and that appropriate medical follow-up did not occur with the residents. It was also alleged staff was not notified or given proper instructions on handling contagious residents. Records reviewed revealed Resident #8 was diagnosed with scabies on 8/25/2020, Resident #6 on 8/27/2020 and Resident #13 sometime later that year. Interviews with staff revealed that they were never trained on how to handle residents with scabies or C-diff. Staff #1, who was the administrator at the time stated that Resident #6 and #8 did in fact have scabies. Per staff #1 both residents were room mates. Interviews with staff stated that Resident #8 had scabies first and later gave it to Resident #6. Per Staff #1, hospice said it was not scabies and later determined that it was. It was never reported to CCL. Staff #1 stated the Licensee, staff and families were notified. LPA received documents on todays visit from the County of Los Angeles Public Health being notified and a case being opened.

In regards to allegation: Facility is in disrepair - it was alleged the facility had broken beds, clogged toilets, plumbing issues and the facility was in disrepair. (Continued on an LIC 9099C)
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 28-AS-20201124163559
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: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2021
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature......
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Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date.
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This requirement was not met as evidence by: The Administrator was notified and aware about the sexual abuse Resident #9 was doing to other residents and did not take action to mitigate the abuse.
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Type A
11/05/2021
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature......
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Administrator will ensure no residents are tied with bedsheets and will conduct personal rights training with all staff. Administrator will provide proof of personal rights training conducted by POC due date. Administrator will submit proof via fax only to LPA.
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This requirement was not met as evidence by:
The facility allowed staff members to tie residents with bedsheets onto the back of their wheel chairs were it was not reachable for residents to un tie themselves.
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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: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 28-AS-20201124163559
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: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/10/2021
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency.....(D) Any incident which threatens the welfare, safety or health of any resident..... .
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Administrator will ensure to report any cases of contagious diseases/infections to CCL immediatelty and provide all cross reporting information made to other agencies. Administrator will submit a plan stating what actions/steps will be taken when there is a case in the facility via fax by POC due date.
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This requirement was not met as by evidence:
The facility had (3) residents diagnosed with scabies and did not report it to CCL. A case was open with the County of Los Angeles public health and CCL was not notified.
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Request Denied
Type B
11/10/2021
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: The Administrator was allowing staff to put residents in Gerry chairs without a physcians order in place and tying residents with bedsheets without any orders.
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stating they have read and understood the section and will abide by it. Administrator will fax documents by POC due date.
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: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 28-AS-20201124163559
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: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/10/2021
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of..... The licensing agency may require any facility
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Administrator will reasses all current residents needs and assess new one's to determine the needs of residents and put a plan of action in place to ensure the facility has the appropriate staffing. Administrator will submit a staff schedule and a LIC 500 by POC due date via fax to LPA.

Staffing agencies???
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to provide additional staff whenever it determines..... .

This requirement was not met as evidence by:
The Administrator did not provide sufficient staff to assist all residents in care which resulted in residents not being assisted with their ADL's at times.
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Request Denied
Type B
11/10/2021
Section Cited
CCR
87468.1(a)(2)
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87468 Personal Rights
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidence by:
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Administrator will ensure all resident have a bed frame and will replace or sanitize any dirty or ripped mattresses and/or box springs. Administrator will ensure extra bed frames and mattress are available on the premesis by POC due date and will submit proof via fax to LPA.
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The facility had dirty matresses, ripped box springs and broken closet room doors. Images also provided showed a resident sleeping on a matress on the floor without a bed frame
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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: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 28-AS-20201124163559
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: 11/03/2021
NARRATIVE
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Interviews with staff indicated the facility did have plumbing issue but was later fixed. Interviews with staff revealed the mattresses were dirty and old and some were placed directly on the floor without box springs or bed frames. Interviews also reveal that there is broken closet doors inside a resident's room. Picture was obtained. LPA obtained pictures of dirty mattresses with what appeared to be feces. LPA also obtained a picture with a ripped box spring with pillows in between the mattress and box spring and a resident laying on the bed and pictures of dirty mattresses.

In regards to allegation: Residents are not provided with general hygiene supplies - it was alleged the facility had no soap, paper towels, and toilet paper and that the Administrator would lock away supplies making it inaccessible to staff during their shift. Based on interviews conducted, during the night shift staff couldn't ask for supply because management was not on the premises and would run out of supply during the night shift. Staff also stated that even during the day they do not get supply because the facility always runs out. Caregivers stated they had to use the same shampoo, bar soap, hairbrush, deodorant and toothpaste for all residents. Per caregivers, it's the facilities practice for each staff to carry their own small bucket with hygiene supply and assist the residents. The only thing the resident have of their own is their toothbrush. Staff also stated they would run out of wipes.

Based on records reviewed, evidence, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies cited under California Code of Regulations Title 22 . Immediate Civil Penalties of $500 is being issued.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49 (f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).

An exit interview was conducted with Assistant Administrator, Laura Hernandez and Caregiver Elvira Cortez and hard copy of this report was provided along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Linda M Almaraz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 28-AS-20201124163559
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: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/10/2021
Section Cited
CCR
87307(a)(3)(D)
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87307 Personal Accomadations and Services (a) Living accommodations and grounds shall be related to the facility's function..... The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident....
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Administrator will purchase extra hygiene and ensure each resident has their own personal hygiene and ensure staff have access to the supply when needed. Administrator will submit picture of supply available to LPA via fax only by POC due date.
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(D) Hygiene items of general use such as soap and toilet paper.
This requirement was not met as evidence by: Based on in interviews conducted the facility would run out of hygiene supply and when there was some it was inaccesible to staff, specially during the night shift. Residents had to share deodorant, shampoo, soap and hair brush's.
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Request Denied
Type B
11/10/2021
Section Cited
CCR
87415(a)(2)
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87415 Night Supervision
(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures,.... and shall be available as indicated below to assist in caring for residents in the event of an emergency.
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Administrator will ensure at least 2 staff are on shift when there is more than 14 residents at the facility or they determine they need 2 caregivers based on the residents needs. Administrator will send a signed statement stating their plan of action by fax by POC due date.
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(2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes.
This requirement was not met as evidence by: Only one caregiver was on shift at night, several times and was not able to assist all residents with their ADL's
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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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 10 of 10