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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 10/11/2024
Date Signed: 10/11/2024 02:16:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
09/07/2023 and conducted by Evaluator Sanjay Vaid
COMPLAINT CONTROL NUMBER: 28-AS-20230907141335
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: 37DATE:
10/11/2024
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Administrator, Laura HernandezTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Due to staff neglect, resident fell resulting in injury.
Staff did not seek timely medical care for resident
Staff did not follow resident's fall plan
INVESTIGATION FINDINGS:
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*** This licensing report issued on 10/11/2024 supersedes that licensing report dated 09/12/24, LPA Vaid obtained additional information, however, the investigation findings will remain the same***

Licensing Program Analyst (LPA) S. Vaid conducted a subsequent complaint visit regarding the allegations listed above to reissue the report and to reissue citation for the investigated complaint findings.

On 09/08/2023, Program Analyst (LPA) V. Maldonado made an unannounced initial visit to the facility to conduct a Health and Safety check inspection, in response to the above-mentioned allegations. LPA met with staff Elvira Cortez and explained the purpose for the visit. Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas with assistance of staff Daisy Fitter, and obtained the following documents for Residents# 1-4 (R1-R4): Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA did not observe any immediate health and/or safety concerns.
Coninued on 9099C.........
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
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 4
Control Number 28-AS-20230907141335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 10/11/2024
NARRATIVE
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On 08/20/2024. Licensing Program Analyst (LPA) S Vaid made an unannounced subsequent visit to the facility to conduct further investigations, in response to the above-mentioned allegations. LPA met with the staff Daisy Fitter and explained the purpose for the visit. Administrator Laura Hernandez joined shortly after. The investigation consisted of the following: Review of staff and resident rosters, tour of the physical plant with Administrator and viewed common areas and resident rooms. Obtained and reviewed the following documents for Residents# 3: Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA interviews with four (4) staff members and two (2) residents. Investigation Branch, Investigator Olivia Spindola conducted further investigation.

Regarding the allegation: 1) Due to staff neglect, residents fell resulting in injury, 2) Staff did not seek timely medical attention for the resident and 3) Staff did not follow the resident’s fall plan. Four (4) out of four (4) staff denied the allegation and reported they were following the orders and instructions given by management staff. Two out of Two (2) residents could not corroborate the allegation and stated they were not aware of the incident happening at the facility. It is alleged that on 09/01/23, in the early morning, resident R3 had an unwitnessed fall and sustained injuries. Staff/Caregivers discovered R3 on the floor near the R3’s bed. Staff put R3 back in bed and staff did not notify the Facility Administrator of R3s fall. Staff did not assess R3 after the fall. According to staff statements (investigated by Spindola), the morning staff/caregiver mentioned R3 was feeling very sore and complained of pain. Staff/caregiver(s) did not perform a fall assessment to R3. After breakfast, upon rising from R3’s dining seat, R3 screamed in pain and staff sent R3 to Pomona Valley Hospital for emergency medical care. Investigator Olivia Spindola conducted further investigation. R3 was sustained multiple fractures; fracture to the left ribs, punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The Individual Service Plan dated 02/16/2023, received by Mountain View facility, noted that R3 was totally dependent, and required assistive devices for mobility; needs walker and wheelchair, shower chair. Section C page 9 of the assessment tool indicated R3 is at risk for falls. Section C page 24 identifies risks to personal safety; potential for falls, unsteady gait and fall history. R3’s resident appraisal dated 03/17/2023, indicated under services needed: balance is off, very wobbly. Bathing: needs to be monitored so they do not fall. R3’s Functional Capability Assessment dated 03/17/2023 indicated balance is off. On 06/03/23, R3 had a fall in the patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off R3s bed and hit their head.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230907141335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 10/11/2024
NARRATIVE
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 In the early morning hours of 09/01/2023, caregiver found R3 on the floor near R3s bed, and put R3 back into bed without assessing them. Overnight shift staff/caregivers did not inform the facility administrator of R3s fall and staff did not seek immediate medical attention for R3 after the 09/01/2023 fall. Staff neglected to render R3 assistance in meeting necessary medical assessment needed when fall occurs and pain is displayed, due to fall plan not being followed as shown in the documents reviewed.

Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to staff neglect resulting in injury. Refer to LIC 421IM***
The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). If the department determines the injury of the resident is due to neglect.
Exit interview was conducted with Laura Hernandez and a copy of this report, LIC 9099D, LIC 421 and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230907141335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2024
Section Cited
CCR
87468.2(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Administrator will give caregiving staff and direct staff personnel, training for understanding the care as listed in the residents’ IPP (Individual Program Plan) and residents’ personal rights by due date 10/25/24.
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This requirement was not being met as evidenced by:
Based on record review, facility person(s) responsible for reviewing and implementing a residents Fall Care Plan, failed to give proper instructions to the residents’ caregiving staff. Resulting in the resident sustaining injuries. As indicated in SIR 09/01/23 and hospital report dated 09/04/23.
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On 10/11/24:Proof of correction was provided with Staff In-Service training for Falls,Resident Care, precautions and fall precautions, emergency procedures, hospice 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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4