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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 11/01/2024
Date Signed: 11/01/2024 02:21:09 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
PUBLIC
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:
11/01/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator-Laura HernandezTIME COMPLETED:
12:00 PM
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 today’s visit, 11/01/2024 supersedes that licensing report dated 10/11/2024, LPA Vaid is reissuing the report and citations, 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:

Continued 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: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
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 6
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: 11/01/2024
NARRATIVE
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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.

Regarding the allegation: Due to staff neglect, residents fell resulting in injury, it was 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. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported to being aware that R3 has a history of fall and R3s family member supplied the facility with a Life Station device that would alert 911 if R3 fell in the facility, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. Resident #3 was moved to healthcare facility and was not interviewed during the investigation due to R3’s cognitive impairment. The investigation revealed that on 08/31/23, R3 fell in the facility and staff were aware of R3s fall, staff did not assess R3 for injury and did not inform the administrator of R3s fall. Additionally, staff did not seek immediate medical treatment for R3 after the 09/01/23 fall. R3 was taken for medical treatment the next day. The hospital staff assessed the R3 and observed R3 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 facility did not properly assess R3 for injury after the R3’s fall, and it was discovered on 09/01/23 that R3 sustained serious injury.

Regarding the allegation: Staff did not seek timely medical attention for the resident, it was alleged that on 09/01/23, resident R3 had an unwitnessed fall and sustained injuries. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported that R3 has a history of fall and R3s family member supplied the facility with a Life Station device that would alert 911 is R3 fell, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Staff present during the night shift did not report obtaining medical treatment for R3 after the 08/31/23 fall.
Continued on 9099C....
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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: 11/01/2024
NARRATIVE
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Administrator reported staff did not notify her of the 08/31/23 fall. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. Resident #3 was moved to healthcare facility and was not interviewed during the investigation due to R3’s cognitive impairment. The investigation revealed that on 08/31/23, R3 fell in the facility in early morning, staff placed R3 back in resident’s bed, did not make administrator aware of R3s fall, did not assess R3 for injury and did not obtain timely medical attention for R3 after the fall. R3 was sent out for medical treatment the next day, 09/01/23. Hospital staff observed R3 had 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.

Regarding the allegation: Staff did not follow the resident’s fall plan, it was alleged that on 09/01/23, in the early morning, resident R3 had an unwitnessed fall and sustained injuries. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported to being aware that R3 has a history of falls and staff were aware that R3 would get out of bed at night to urinate. R3s family member supplied the facility with a Life Station device that would alert 911 if R3 fell in the facility, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. R3 is currently deceased and was not interviewed during the investigation due to R3’s cognitive impairment. Per the investigation, review of R3s records, it was observed that R3s Individual Service Plan dated 02/16/2023 noted that R3 was totally dependent, needed assistive devices; needed a walker and wheelchair, and shower chair. Section C page 9 of the R3’s assessment tool indicated that R3 requires assistance with ADLs due to weakness, fatigue, confusion and R3 is at risk for falls. Page 24 indicated the risks to R3s personal safety, as potential for falls, unsteady gait, and a fall history. R3’s resident appraisal dated 03/17/2023, indicated under services needed: R3 needs help getting up due R3’s balance and R3 being very wobbly. Bathing: R3 needs to be monitored so they do not fall. R3’s Functional Capability Assessment dated 03/17/2023 indicated R3’s balance is off. Additionally, on 06/03/2023, R3 had a fall in the facility patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off their bed and hit R3s head. On 08/31/2023 around 11:30PM , staff found R3 on the floor near R3s bed, and put R3 back into bed without assessing R3 for injury. Continued on 9099C.........
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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: 11/01/2024
NARRATIVE
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Staff did not inform the administrator of R3’s fall and staff did not seek immediate medical attention for R3 after the fall. The investigation revealed that staff did not follow R3s fall plan as R3 was admitted to the facility with a history of falls, required assistance to getting up due balance issues, and had two prior falls in the facility on 06/03/24 and 06/22/24. Staff did not render services needed for R3 as required per R3’s resident assessment/fall plan risk dated 02/16/23 that indicated the following: staff to assist R3 with ADL, staff to assist supervise/assist R3 with ambulation and transfer, staff monitor for R3 fall, the lack of care and supervision, resulted in R3 falling the facility on 08/31/24, which resulted in R3 sustaining injury that required medical treatment.

Based on IBs and LPA's interviews conducted and 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.

***Immediate Civil Penalty in the amount of $500.00 is being issued today, due to staff neglect resulting in R3’s 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: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Addtional Personal Rights of Residents in Privately Operated Facilities. (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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Administrator will give provide staff and direct staff personnel, training for understanding the care as listed in the residents’ careplans and residents’ personal rights by due date 11/08/24.
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(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. This requirement was not met as evidenced by: Staff did not asses R#3 for injury after fall and staff didnot follow R3's careplan
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Administrator will send a letter to licensing indicating Licensee has read and will comply section 87468 by 11/02/24.
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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: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2024
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care.(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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Administrator will give direct staff personnel, training for fall precautions, emergency procedures, reporting procedures by due date 11/08/24.
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(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Resident not receiving timely medical assistance.
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Administrator will send a letter to licensing indicating Licensee has read and will comply section 87465 by 11/02/24.
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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: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6