197801605-2-14-2023-28-AS-RORN-CQ6N43-20230322100716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 02/14/2023
Date Signed: 02/14/2023 04:37:42 PM

Unsubstantiated

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
12/29/2022 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221229092451

FACILITY NAME:	MOUNTAIN VIEW CENTER		FACILITY NUMBER:	197801605
ADMINISTRATOR:	LAURA HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	715 WEST BASELINE ROAD		TELEPHONE:	(909) 626-6633
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	40	CENSUS: 33	DATE:	02/14/2023
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Laura Hernandez		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.
Resident was not provided proper eviction notice.
Staff did not notify authorized representative about injuries.
Resident room is not properly cleaned resulting in room is malodorous.
Resident not provided adequate sleeping conditions.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegations and for the purpose of rendering the findings. LPA met with Staff #1 Yvonne Montaya who allowed entry into the facility and was later met by Administrator Laura Hernandez who assisted with the visit.

The investigation consisted of the following: On 1/5/2023, LPA interviewed S1 and S2 and obtained copy of resident and staff roster and Resident#1 (R1)'s Identification and Emergency Information, Hospice physician order form, hospice training log, discharge medication, notification of initiation of hospice services, Individual Service Plan (ISP), Hospital Record from Pomona Valley Hospital, Progress Notes, physician report dated on 11/30/22 and Functional Capacity Assessment and Admission Agreement. On today's date, LPA interviewed additional three staff (S3-S5) and administrator, and four clients (R2-R5) and one resident's family via telephone.
(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20221229092451

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: 02/14/2023

NARRATIVE

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The investigation revealed of the following: Allegation#1 "Resident sustained unexplained injuries while in care." LPA interviewed staff and reported when R1 first admitted to the facility. R1 already came with a lot of skin tears on his arms and staples on his forehead. The administrator also stated that R1 likes to jump out from the hospital bed rail and wheelchair when R1 feels agitated which may caused some skin tears on his hands or arm. Hospice also reported when R1 felt agitated. R1 may bite or scratch himself which caused the skin tears but R1's skin condition was resolved.

Allegation#2 "Resident was not provided proper eviction notice. " LPA interviewed administrator and reported facility never planned to evict R1. The facility never provided any eviction notice to resident or family members. It was the agreement between R1's family and hospice agency and family decided to send R1 back home and live with the family.

Allegation#3 " Staff did not notify authorized representative about injuries." LPA interviewed four residents and all denied the allegation. They all reported anything happened to them, the staff or facility would notify their family members or authorized representatives immediately. They never delayed reporting. The resident's family also reported facility is on top of notifying family members. The administrator also stated that if resident fell and was unable to move or in any serious condition, they usually would call 911 immediately and then they would notify hospice and family or authorized representatives at the same time.

Allegation#4 "Resident room is not properly cleaned resulting in room is malodorous. " LPA interviewed four residents and all reported their room are clean, nice and with no smell. LPA interviewed staff and reported sometimes residents may have accident on their bed and it definitely smelled bad but they would change the bedsheet right away and open up the window for the fresh air. Staff also clean residents' room every day. LPA also toured residents' rooms and they are all in sanitary and free of odor.

Allegation#5 "Resident not provided adequate sleeping conditions." LPA interviewed four residents and all reported they all sleep in their own bed and have a good sleeping environment and conditions. LPA interviewed staff and reported all residents sleep in their bed. The administrator stated R1 had a full hospital bed rail since day one through the hospice agency.

(See LIC 9099C for continuation)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20221229092451

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: 02/14/2023

NARRATIVE

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On the first week, R1 was very agitated, R1 always wanted to jump out of the bed rail and screamed in the middle of the night. Therefore, staff tried to placed R1 in different area including the sofa in the living room or the wheelchair to get R1 comfortable but nothing works. Staff would place R1 back to the bed in his room and stay with R1. Administrator reported R1 always sleep on the bed and R1 never slept in a booster type chair.

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 allegations are found to be UNSUBSTANTIATED.

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

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

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