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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 02/06/2023
Date Signed: 02/06/2023 12:49:38 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 Kruz Long
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20201210143607
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:
02/06/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Laura Hernandez (Administrator)TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Resident fell while in care.
Resident sustained bruises while in care.
Staff tied resident to the bed.
Staff not meeting resident's hygiene needs.
INVESTIGATION FINDINGS:
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2
3
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5
6
7
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10
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13
***This report supersedes the report LIC9099 dated 12/29/22.***

Licensing Program Analyst (LPA) Kruz Long conducted a subsequent complaint investigation at the facility. Upon arrival, LPA met with Laura Hernandez (Administrator) and explained the purpose of the visit.

During today's visit, LPA requested proof or documentation indicating the facility notified the authorized representative for Resident #1 of a fall incident which occurred on 09/08/20. Facility was not able to provide proof or documentation.

During the initial visit conducted on 12/17/20, LPA interviewed Staff #1 and requested a copy of the Staff/Resident roster.

Continue to LIC9099C.....
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
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
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 Kruz Long
COMPLAINT CONTROL NUMBER: 28-AS-20201210143607

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:
02/06/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Laura Hernandez (Administrator)TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has a scabies outbreak.
Staff did not notify resident's authorized representative of incidents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
***This report supersedes the report LIC9099 dated 12/29/22.***

Licensing Program Analyst (LPA) Kruz Long conducted a subsequent complaint investigation at the facility. Upon arrival, LPA met with Laura Hernandez (Administrator) and explained the purpose of the visit.

During today's visit, LPA requested proof or documentation indicating the facillity notified the authorized representative for Resident #1 of a fall incident which occurred on 09/08/20. Facility was not able to provide proof or documentation.

During the initial visit conducted on 12/17/20, LPA interviewed Staff #1 and requested a copy of the Staff/Resident roster.

Continue to LIC9099C...
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20201210143607
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: 02/06/2023
NARRATIVE
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28
29
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32
***This report supersedes the report LIC9099C dated 12/29/22.***

During a subsequent visit dated 12/29/22, LPA obtained/reviewed a copy of the Staff/Resident rosters and Resident #1's (R1) records, interviewed Staff #2 to Staff #6 in the library and interviewed Resident #2 to Resident #5 in the library.

In regards to the allegation: Facility has a scabies outbreak. Based on complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the time frame of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated.

In regards to the allegation: Staff did not notify resident's authorized representative of incidents. Interviews with Staff indicate the authorized representative is notified if there is an incident with the Residents. Based on allegation details, R#1 had an un-witnessed fall on 09/08/20. Hospice notes indicate the hospice agency notified the authorized representative of the incident but there are no records that indicate the facility notified R#1's authorized representative.

Based on the department's record review, evidence and interviews, in the investigation revealed: The preponderance of evidence standard has been met, therefore the above allegations are 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 conducted with Laura Hernandez and a copy of this report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20201210143607
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: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2023
Section Cited
CCR
87411(a)
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2
3
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6
7
87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Cleared during visit. The department was provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.
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Based on complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the timeframe of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated.
8
9
10
11
12
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14
Type B
02/20/2023
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements
(a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:
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Licensee shall review section 87211 and provide a signed statement to the department by the POC date indicating the Licensee understands and will report to the department and Resident's authorized representatives of similar incidents which may occur in the future.
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There are no records that indicate the facility notified R#1's authorized representative that R#1 had an un-witnessed fall on 09/08/20.
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9
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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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20201210143607
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: 02/06/2023
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
***This report supersedes the report LIC9099C dated 12/29/22.***

During a subsequent visit dated 12/29/22, LPA obtained/reviewed a copy of the Staff/Resident rosters and Resident #1's (R1) records, interviewed Staff #2 to Staff #6 in the library and interviewed Resident #2 to Resident #5 in the library.

In regards to the allegation: Resident fell while in care. Interviews with 6 of 6 Staff indicated they do not recall whether R1 had a fall while residing in the facility. Records indicate R1 had an un-witnessed fall on 09/08/20 while under Hospice care. Per Hospice notes, R1 denied pain and plan of care to continue.

In regards to the allegation: Resident sustained bruises while in care. Review of R1's medical records indicate R1 has a medical condition resulting in progressive movement which caused R1 to be susceptible to bruising. Interviews with Staff and review of the Individual Services Plan indicate preventable measure were put in place to prevent R1 from bruising due to the medical condition.

In regards to the allegation: Staff tied resident to the bed. Interviews with 5 of 5 Staff indicate they have never tied a Resident to the bed. Interviews with 4 of 4 Residents indicated they have never been tied to a bed.

In regards to the allegation: Staff not meeting resident's hygiene needs. Interviews with indicated Residents are meeting the Resident's hygiene needs. Interviews with 4 of 4 Residents indicate their hygiene needs are being met.

Based on LPA's interviews and record review, the investigation revealed: Although the allegations may have happened or is 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 conducted with Laura Hernandez and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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