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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 04/21/2022
Date Signed: 04/21/2022 01:09:39 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 Christine Wong
PUBLIC
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: 19DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Laura Hernandez TIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
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8
9
Resident had unexplained injury
Staff did not notify authorized representative of residents injury
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Wong conducted an unannounced subsequent visit to interview additional residents for the above allegations. LPA met with receptionist Daisy Fitter and explained the reason of the visit and shortly after, the assistant administrator Laura Hernandez arrived and assisted with the visit.

On 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. On today's date, LPA Wong interviewed three residents (R2-R4) and reviewed three residents' file.

(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
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 4
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: 04/21/2022
NARRATIVE
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The investigation revealed of the following: Allegation#1 "Resident had unexplained injury" it was alleged Resident #1 received a black eye while living at the facility. 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. LPA also interviewed residents and residents families and reported residents they never had any unexplained injury and the staff take good care of them and they are doing their best for the residents.

Allegation#2 "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. LPA also interviewed the residents and residents families and reported the facility staff always notified the authorized representative with any concerns of the residents. The staff are on top of it and they always provide good care to the residents. They have no concerns or complaints about the facility.

Based on the additional residents interviews conducted, the complaint investigation findings remain the same: UNSUBSTANTIATED.

Exit interview was conducted with the Assistant Administrator Laura Hernandez and a hard copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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 Christine Wong
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: 19DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Laura Hernandez TIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff restrained resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Christine Wong conducted an unannounced subsequent visit to interview additional residents for the above allegation. LPA met with receptionist Daisy Fitter and explained the reason of the visit and shortly after, the assistant administrator Laura Hernandez arrived and assisted with the 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. On today's date, LPA Wong interviewed three residents (R2-R4) and reviewed three residents' file.

(See LIC9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
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 4
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: 04/21/2022
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 the interviews conducted and the prior investigation, the complaint investigation findings remain the same: SUBSTANTIATED.

Exit Interview Conducted and a copy of the report was provided to Assistant Administrator Laura Hernandez.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4