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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 05/03/2022
Date Signed: 05/03/2022 09:51:39 AM

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
04/25/2022 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220425111119
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: 20DATE:
05/03/2022
UNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Administrator, Laura HernandezTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility did not comply with the terms of the license revocation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Administrator, Laura Hernandez and explained the reason for the visit.

The investigation consisted of the following: Administrator was interviewed and facility was toured.

The investigation revealed the following: It's alleged facility has not complied with the terms of the license revocation. On 4/14/22, LPA Irra visited the facility to ensure the Accusation No. 6221326301D was posted as required by law. At the time the Accusation was not posted. The facility was given a Plan of Correction (POC) to post the Accusation and notify in writing the residents' responsible parties and the Ombudsman as required by law. On 4/28/22, LPA Irra returned to the facility to ensure the Accusation was posted and all required parties were notified. The Accusation was posted, however the responsible parties and the Ombudsman were not notified in writing as required. LPA Irra issued civil penalties for the POC not being cleared.
Continued on 9099C.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
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 3
Control Number 28-AS-20220425111119
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: 05/03/2022
NARRATIVE
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During today's visit the facility was toured and the Accusation dated 4/8/22 was seen posted in a frame at the entrance of the facility. Administrator was interviewed and confirmed the Ombudsman and the residents' responsible parties have not been notified in writing about the Accusation as required by law. Administrator indicated the Licensee's attorney is drafting a letter that will be sent to all required parties soon.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. Health and Safety Code Title 22, Division 6 and Article 3 are being cited on the attached LIC 9099D.

Exit interview held. A copy of the report, appeal rights and civil penalty form were provided to Administrator.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220425111119
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: 05/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2022
Section Cited
HSC
1569.38(b)(1)
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Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events:
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Facility will provide proof to the department that all residents' responsible parties and the Ombudsman have been notified in writing of the Accusation.
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(1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50.
This deficiency was evidenced by the following: Accusation is dated 4/8/22 and Administrator confirmed responsible parties and Ombudsman have not been notified in writing.
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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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3