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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 08/12/2022
Date Signed: 08/12/2022 03:03:42 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
12/10/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201210145037
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: 25DATE:
08/12/2022
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Staff #1 (S1)TIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Facility is not following reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo and Yang conducted a subsequent complaint visit to investigate the allegations listed above. The initial complaint visit was conducted by LPA Rivas on 12/16/20. A subsequent complaint visit was conducted by LPA Vasallo on 3/18/22. LPA met with Staff #1 (S1) and explained the reason for the visit.

The investigation consisted of the following: LPA Rivas interviewed licensee representative, Trupti Mody a medication technician (Med Tech) and 2 caregivers. During the subsequent complaint visit, LPA Vasallo reviewed Resident #1's (R1's) records. LPA also interviewed 4 staff and requested and obtained copies of staff training records from 2020 and R1's hospice documents from 2020. After the subsequent complaint visit another staff member was interviewed along with the Long Term Care Ombudsman.

The investigation revealed the following: It’s alleged facility did not report positive COVID cases or scabies cases. 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: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
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 5
Control Number 28-AS-20201210145037
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: 08/12/2022
NARRATIVE
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LPA reviewed the department's database and confirmed facility reported several COVID cases in July and August of 2020. However, the facility did not report that 3 residents were diagnosed with scabies in August 2020. Based on the information obtained, the allegation is substantiated.

Based on records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview held. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20201210145037
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: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements: 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 was called and agreed to send a written statement that facility will report all communicable/contagious diseases to CCL in a timely manner.
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This deficiency was evidenced by the following: 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, CCL was not notified.
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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: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
12/10/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201210145037

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: 25DATE:
08/12/2022
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Staff #1 (S1)TIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff handle resident in a rough manner
Staff are not following resident's care plan
Resident(s) sustained multiple pressure injuries due to neglect
untrained staff are assisting with medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo and Yang conducted a subsequent complaint visit to investigate the allegations listed above. The initial complaint visit was conducted by LPA Rivas on 12/16/20. A subsequent complaint visit was conducted by LPA Vasallo on 3/18/22. LPA met with Administrator, Laura Hernandez today and explained the reason for the visit.

The investigation consisted of the following: LPA Rivas interviewed licensee representative, Trupti Mody a medication technician (Med Tech) and 2 caregivers. During the subsequent complaint visit, LPA Vasallo reviewed Resident #1's (R1's) records. LPA also interviewed 4 staff and requested and obtained copies of staff training records from 2020 and R1's hospice documents from 2020. After the subsequent complaint visit another staff member was interviewed along with the Long Term Care Ombudsman.

The investigation revealed the following: Allegation - Staff handle resident in a rough manner. It’s alleged R1 had bruising as a result of being handled rough by staff. Continued on 9099C.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
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 5
Control Number 28-AS-20201210145037
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: 08/12/2022
NARRATIVE
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Staff interviewed denied ever seeing staff be rough with residents and denied any abuse. LPA obtained pictures of R1’s bruising. The bruising appears as light red in color on the upper lip, left cheek bone, left side of forehead and elbow. R1 was unavailable to be interviewed and there were no other witnesses to the alleged incident. Hospice documents were reviewed and there were no concerns noted. Residents have severe dementia and therefore, were not interviewed. Based on the information obtained, the allegation is unsubstantiated.

Allegation - Staff are not following resident's care plan. R1’s care plan was reviewed. Staff were interviewed and indicated all services were being provided to R1. R1 is unavailable to be interviewed as R1 was discharged from this facility in 2020. Hospice documents were reviewed and there were no concerns noted. Based on the information obtained, the allegation is unsubstantiated.

Allegation - Resident(s) sustained multiple pressure injuries due to neglect. Staff interviewed denied that R1 had any pressure injuries. R1 is unavailable to be interviewed. R1’s file was reviewed which included care plan, hospice documentation, hospital notes, and nurses notes. There was no documentation that R1 had any pressure injuries. There was no documentation or witnesses to confirm that R1 had pressure injuries. Therefore, the allegation is unsubstantiated.

Allegation - Untrained staff are assisting with medications. It’s alleged that in 2020 facility staff were not trained in medication assistance. Interviews conducted with staff did not corroborate the allegation. Staff files were reviewed, and they contained the required staff medication training. Medication records were reviewed and they did not corroborate the allegation. There was no evidence that staff was ever responsible for a medication error. Based on the information obtained, the allegation is unsubstantiated.

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.

Exit interview held. A copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Tony Vasallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5