<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 08/16/2022
Date Signed: 08/17/2022 01:03:12 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
12/10/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201210153051
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:
08/16/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator, Laura HernandezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not report incidents to Authorized Representative.

Resident has had multiple falls.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Daisy Fitter, Receptionist). LPA/RA spoke to Asst. Administrator (A2: Elvira Cortez) upon entering the facility to conduct a risk assessment. A2 informed LPA that the facility has no "new" COVID cases nor do any of the residents or staff have symptoms. The purpose of this visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. The initial 10-Day virtual visit was conducted by LPA Angelica Rea on 12/21/20 (via telephone) with On-Call Administrator (A3: Trupti Moody) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed Administrator, (6) facility staff members, and did not interview Resident #1 or Resident #2 who moved or (0) residents due to their cognitive impairment (approx.) 9:15 am - 10:30 am. LPA/RA Ceniceros reviewed documentation (Admission Agreement, Emergency I.D. and Information, Physician's Report, Appraisal/Needs and Services Plan, Incident Reports, Home Health Agency Record, Facility Progress Notes) for Residents #1 and #2 (from 8:10 am - 9:15 am).
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
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 2
Control Number 28-AS-20201210153051
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: 08/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding Allegation #1: this investigation revealed Resident #1's Unusual Incident/Injury Report (dated 12/13/20) was submitted to CCLD regarding Resident #1's diagnosis and receiving the treatment; however, when the facility received the results, Resident #1 had already moved out of the facility on 12/11/2020 by the Public Guardian. Resident #2's Unusual Incident/Injury Report was submitted to CCLD on 12/15/20 regarding an incident that occurred on 12/11/20 regarding personal rights. Based on reporting incidents, the facility documented and made the appropriate notifications to Resident #1 and #2 authorized representative.

Based on evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation of REPORTING REQUIREMENTS: Staff do not report incidents to Authorized Representative is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed that Resident #1's functional capabilities (based on a Record Assessment, dated 01/28/19), the resident does not use a brace or crutch or walker, but uses a wheelchair and can get in and out unassisted. A review of the "Physician's Report" (dated 01/17/19), documented Resident #2 is ambulatory and under "Physical Health Status" the resident does not require assistive device and is in fair condition. A review of the "Facility Progress Notes" (from 05/14/20 to 09/08/20) documented the resident's last known fall at the facility on 05/14/20 at 2:10 p.m. Resident #1 had become more anxious and agitated in the evenings and fell out of bed and out of the recliner chair. Based on interviews conducted of facility staff, the majority indicated that Resident #1 had a home health (Care More) nurse practioner that would visit the resident once a week. Facility staff had not witnessed Resident #1 to be found on the floor covered in feces during their shift rounds. Resident #1 would slide out of its bed or the recliner; however, there had not been reported falls up until the time that Resident #1 moved on 12/11/20.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE: Resident has had multiple falls is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Administrator, Laura Hernandez.

NAME OF LICENSING PROGRAM MANAGER: Araceli Ramirez
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Ceniceros
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2