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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 07/12/2022
Date Signed: 07/12/2022 01:04:37 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
11/25/2020 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201125084256
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: 24DATE:
07/12/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elvira Cortez and Laura HernandezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not seek timely emergency medical services for resident.
Staff prevent resident from making and receiving phone calls.
Medication not properly discarded.
Facility has mold.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Elvira Cortez and discussed the purpose of today's visit. Laura Hernandez (Facility Administrator) arrived at approximately 1010AM and assisted with today's visit.

On 04/14/22, LPA Irra conducted a subsequent visit to investigate the above allegations. LPA met with Laura Hernandez (Assistant Administrator/S-2) and discussed the purpose of the visit. During this visit, LPA Irra conducted a facility tour, reviewed Resident #1 through Resident #6 (R-1 through R-6) files and obtained relevant documentation. LPA Irra also interviewed Staff #2 through Staff #4 (S-2 through S-4) The initial 10 day investigation visit was conducted on 11/30/2020 by LPA Linda Almaraz. The following occurred during this visit: LPA conducted a virtual tour of the living room, dining area, kitchen, outside patio, common areas and resident rooms. 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 interviewed Licensee and Staff #1. Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
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 7
Control Number 28-AS-20201125084256
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: 07/12/2022
NARRATIVE
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Allegation: Staff did not seek timely emergency medical services for resident. During this investigation, LPA reviewed resident files. Per file review, 911 was called due to R-6 choking. Per documentation reviewed, R-6 was choking during mealtime, staff performed CPR and Heimlich Maneuver and 911 was called for assistance. R-6 was taken to the local hospital and was treated. Staff interviews also revealed that staff did seek emergency medical services for R-6. R-6 was unable to be interviewed as R-6 moved out from this facility. Staff interviews and file review does not corroborate this allegation.

Allegation: Staff prevent resident from making and receiving phone calls. During this investigation, facility tours (virtual and in person) were conducted, Resident #1 through Resident #6 (R-1 through R-6) files were reviewed and relevant documentation was obtained. LPA Irra conducted in person tours and observed telephone to be operational and accessible to residents. Staff interviews were also conducted. Per staff interviews, residents are not prevented from making nor receiving phone calls. However, per staff interviews, most residents residing at this facility do not use the telephone often due to their dementia and/or family involvement. Per staff interviews, staff are trained in resident rights. LPA was unable to interview R-1, R-2, R-3, R-4 and R-6 as they are no longer residents at this facility. R-5 was resting during today’s visit. During today’s visit, LPA interviewed R-7, R-8, R-9. Resident interviews revealed that residents are able to make and receive phone calls. Interviews conducted do not corroborate this allegation.

Allegation: Medication not properly discarded. During this investigation, staff interviews were also conducted. Per staff interviews, staff properly discard medications. Staff interviews revealed they are trained in medication administration including destruction of medication. LPA was unable to interview R-1, R-2, R-3, R-4 and R-6 as they are no longer residents at this facility. R-5 was resting during today’s visit. During today’s visit, LPA interviewed R-7, R-8, R-9. Resident interviews revealed that medication is administered as prescribed. Interviewed residents were not aware of the facility’s medication discarding procedures. Interviews and collected documents do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20201125084256
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: 07/12/2022
NARRATIVE
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Allegation: Facility has mold. During this investigation, facility tours (virtual and in person) were conducted, Resident #1 through Resident #6 (R-1 through R-6) files were reviewed and relevant documentation was obtained. LPA Irra conducted in person tours on 04/14/22, 04/28/22, 05/11/22, 05/26/22 and 06/08/22 and did not observe mold in the facility. Staff interviews were also conducted. Per staff interviews, facility does not have mold. LPA was unable to interview R-1, R-2, R-3, R-4 and R-6 as they are no longer residents at this facility. R-5 was resting during today’s visit. During today’s visit, LPA interviewed R-7, R-8, R-9. Resident interviews revealed that the facility does not have mold. Interviews and tours conducted do not corroborate this allegation.

Based on LPA's interviews conducted and records reviewed, investigation revealed: 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 above allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. An exit Interview was conducted, appeal rights and a copy of this report was provided to Laura Hernandez.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
11/25/2020 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201125084256

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: 24DATE:
07/12/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elvira Cortez and Laura HernandezTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident not provided with proper bed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegations. LPA met with Elvira Cortez and discussed the purpose of today's visit. Laura Hernandez (Facility Administrator) arrived at approximately 1010AM and assisted with today's visit.

On 04/14/22, LPA Irra conducted a subsequent visit to investigate the above allegations. LPA met with Laura Hernandez (Assistant Administrator/S-2) and discussed the purpose of the visit. During this visit, LPA Irra conducted a facility tour, reviewed Resident #1 through Resident #6 (R-1 through R-6) files and obtained relevant documentation. LPA Irra also interviewed Staff #2 through Staff #4 (S-2 through S-4) The initial 10 day investigation visit was conducted on 11/30/2020 by LPA Linda Almaraz. The following occurred during this visit: LPA conducted a virtual tour of the living room, dining area, kitchen, outside patio, common areas and resident rooms. 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 interviewed Licensee and Staff #1. Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20201125084256
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: 07/12/2022
NARRATIVE
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Allegation: Resident not provided with proper bed. During this investigation, facility tours (virtual and in person) were conducted and staff interviews were conducted. LPA Almaraz observed R-2’s bed to be on the floor during the virtual tour conducted on 11/30/2020. Staff interviews revealed R-2’s bed was on the floor due to R-2 being a fall risk. LPA Irra conducted tours of this facility on 04/14/22, 04/28/22, 05/11/22, 05/26/22 and 06/08/22 and did not observe any beds to be placed on the floor. R-2 was not interviewed as R-2 moved out of this facility. LPA Almaraz’s observation and staff interviews corroborate this allegation.

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.

An exit Interview was conducted, appeal rights and a copy of this report was provided to Laura Hernandez.
NAME OF LICENSING PROGRAM MANAGER: Christine Yee
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20201125084256
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: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2022
Section Cited
CCR
87307(a)(3)(A)
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Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
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Facility Administrator to ensure each bed is equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. LPA Irra conducted tours of this facility on 04/14/22, 04/28/22, 05/11/22, 05/26/22 and 06/08/22 and did not observe any beds to be placed on the floor. DEFICIENCY CORRECTED.
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(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
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Type B
07/12/2022
Section Cited
CCR
87307(a)(3)(A)
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THIS IS A CONTINUATION OF ABOVE. (A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for matresses and pillows shall be flame retardant.
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Rubber sheeting shall be provided when necessary. This standard is not met as evidence by: LPA Almaraz observed R-2’s bed to be on the floor during the virtual tour conducted on 11/30/2020. Staff interviews revealed R-2’s bed was on the floor due to R-2 being a fall risk.
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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: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7