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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:16:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/26/2023 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230126090555
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: 32DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Laura HernandezTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff illegally evicted resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Laura Hernandez and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Laura Hernandez, Staff 1-4, Resident 2-4 (R2-4), R1's FM, and Witness 1. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of the following documents: Identification and Emergency Information, Physician's Report for Residential Care Facilities for the Elderly (RCFE), Resident Appraisal, Functonal Capability Assessment, CA Assisted Living Waiver Program Individual Service Plan, Progess Notes and Unusual Incident/ Injury Reports dated 9/23/22, 10/6/22, 1/11/23, 1/16/23 and 1/20/23.


(See LIC9099C for continuation)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
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-20230126090555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 02/01/2023
NARRATIVE
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Investigation revealed the following: Regarding allegation, Staff illegally evicted resident, it is alleged that facility administrator texted R1's FM and stated that due to R1's history of eloping, R1 could not return to the facility. R1 has not been served an eviction notice. Interview conducted with facility administrator revealed that administrator did notify R1FM that R1 could not return to the facility due to aggressive behavior towards staff and also their continuous attempts to leave the facility unassisted. Administrator also stated that they told hospital staff that they could not take R1 back. Interview with R1 FM revealed that they received a text message from administrator informing them that R1 could not return to the facility due to incidents that they are aware of involving R1. LPA reviewed R1's progress note dated 1/26/23 which stated that R1 could not be taken back due to physical and verbal abuse. LPA also reviewed a text message sent from facility administrator to R1FM indicating that they could not take R1 back due to for previous incidents. LPA reviewed R1's file and did not observe an eviction notice.

Based on interviews conducted with facility staff, R1FM and review of records, the preponderance of evidence standard has been met, therefore the above stated allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on attached LIC9099D.

Exit interview was conducted with Facility Staff Elvira Cortez.. A copy of the report and appeal rights were
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230126090555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/10/2023
Section Cited
CCR
87224(a)
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87224 Eviction Procedures(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in...

This requirement is not met as evidenced by:
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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Based on LPA interviews and record review, the administrator refusal to accept R1 back to the facility upon discharge from hospital and not providing R1 with a 30 day eviction notice which poses a potential Health, Safety or Personal Rights risk to the residents in care.
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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: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
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
GREATER LA AC/SC, 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
01/26/2023 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230126090555

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: 32DATE:
02/01/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Laura HernandezTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff did not provide adequate supervision resulting in preventing resident from eloping.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Laura Hernandez and explained the reason for the visit.

The investigation consisted of: LPA conducted interviews with Administrator Laura Hernandez, Staff 1-4, Resident 2-4 (R2-4), R1's FM, and Witness 1. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file and collected copies of the following documents: Identification and Emergency Information, Physician's Report for Residential Care Facilities for the Elderly (RCFE), Resident Appraisal, Functonal Capability Assessment, CA Assisted Living Waiver Program Individual Service Plan, Progess Notes and Unusual Incident/ Injury Reports dated 9/23/22, 10/6/22, 1/11/23, 1/16/23 and 1/20/23.


(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
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-20230126090555
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 02/01/2023
NARRATIVE
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Investigation revealed the following: Regarding allegation of, Staff did not provide adequate supervision resulting in preventing resident from eloping, is alleged that R1 has eloped from the facility on various occasions, one in October 2022 and another on January 20,2023. Is is also alleged that R1 got out of the facility and took a taxi to their doctor's office by themselves and later returned to the facility. Interview conducted with administrator revealed that the incident that occurred in October 2022 was addressed on 10/6/22 by LPA Irra and facility is appealing the citation. She also stated that on R1 never took a taxi by themselves and denies that ever occurring. She stated that on January 20, 2023, R1 did not elope from the facility. She stated that she accompanied R1 to the bank and she was with R1 during the whole outing. She stated that during the outing, R1 refused to return to the facility and proceeded to walk away from her and continue to go to different locations by foot. She stated that she was with R1 at a close distance during the whole incident. She stated the incident took place for a couple of hours during which R1 continuously refused to go back to the facility. She had to then call S1 for assistance and the local police department. She stated that when S1 arrived to the location S1 assisted administrator with providing officers with a summary of what happened as she was with R1. She stated that R1 continued to refuse to go back to the facility even though police officers were telling R1 that they had to return. R1 then stated to officers that they were not feeling well and police officers called paramedics and R1 was transported to the hospital. LPA also spoke to R1FM who stated that they did receive a call from the administrator and the police on 1/20/23 informing them of what was happening and that R1 would be hospitalized. LPA Gonzalez reviewed Case Management visit which details the incident that occurred on 10/6/22. LPA also reviewed Unusual Incident/ Injury Report dated 1/20/23 which is reporting the above referenced incident and notifying CCLD of what happened and R1's hospitalization. Interviews conducted with staff revealed that the facility provides proper supervision at all times. Administrator Hernandez denied that the facility does not provide adequate supervision. She stated that she always ensures that the facility is fully staffed to provide proper care and supervision to facility residents. She stated that all staff are also aware of the higher supervision that R1 requires as they have attempted to leave the facility in the past. She stated that there is always someone in the front desk as that is where residents have to go when exiting the facility. Interviews conducted with 3 out of 4 residents revealed that they believe there are enough staff on schedule to provide adequate supervision. R1 was not interviewed as they were not able to be reached by phone. LPA reviewed facility schedule and observed that there is enough staff on schedule to properly oversee residents, facility operation and tend to residents daily needs. Based on interviews conducted with facility staff, facility residents, and LPA record review, there was not enough supportive evidence to concur with the reported allegation.

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 is UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Facility Staff Elvira Cortez.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Alma Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5