197801605-12-10-2024-28-AS-TVAO-DBWU4N-20241213141525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 12/10/2024
Date Signed: 12/10/2024 12:36:24 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
11/18/2024 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241118105915

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: 38	DATE:	12/10/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator Laura Hernandez		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Facility did not maintain liability insurance.
Facility overmedicated resident.
Facility improperly restrained resident.
Facility staff neglect resulted in resident falling and sustaining injuries.
Facility was not feeding resident.

INVESTIGATION FINDINGS:

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*This is corrected version of LIC9099 and LIC9099-C, dated 11/21/24. LPA Ramirez corrected dates only and there are no changes to findings.* Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 11/21/2024 regarding the above allegations. LPA Ramirez was greeted by Administrator Laura Hernandez and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 5 interviews (S1 – S5), Attempted interview of Resident #1 (R1), Interview of Resident#2-3 (R2 – R3), copies of Resident#1 (R1): Medical Assessment (LIC 602A), Hospice Care Training Log, Hospice Progress Notes, Unusual/Special Incident Report (LIC 624) for R1, Medications Administration Record (MAR) for December 2022, Pomona Valley Hospital Medical Center medical reports, Arrowhead Regional Medical Center medical reports, miscellaneous documents related to this investigation, and physical plant tour.
see 9099-C

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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-20241118105915

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: 12/10/2024

NARRATIVE

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The investigation revealed the following. Regarding Allegations: Facility did not maintain liability insurance – It is alleged the facility did not maintain liability insurance during 2022 and does not have current liability insurance. During record review, LPA Ramirez observed liability insurance coverage from 03/09/2022 through 03/09/2025. LPA Ramirez called insurance broker to verify liability insurance is currently maintained and verified coverage limits. 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.

Facility overmedicated resident- It is alleged R1 was overmedicated while receiving care at the facility. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. During record review, LPA Ramirez reviewed R1’s MAR for the month of December of 2022. LPA Ramirez did not observe any notes on MAR, or documentation to collaborate this allegation. Review of hospice progress note did not collaborate this allegation. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Pomona Valley Hospital Medical Center medical report dated 12/19/2022, did not collaborate this 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.

Facility improperly restrained resident- It is alleged facility staff improperly restrained resident and wrapped in a baby highchair. Allegedly, this caused R1’s knee to remain bent and unable to walk anymore. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. During facility tour, LPA Ramirez observed several residents sitting in wheelchairs, recliners, chairs, and couch. LPA Ramirez did not observe a baby highchair at the facility. LPA Ramirez did not observe restraints near chairs, wheelchairs, or recliner. Review of R1’s hospice progress notes and medical notes from Pomona Valley Medical Center, did not collaborate this allegation. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this 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.

See 9099-C for continued report.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20241118105915

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: 12/10/2024

NARRATIVE

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Facility staff neglect resulted in resident falling and sustaining injuries- It is alleged R1 fell and became injured because of staff neglect. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. On 12/17/2022, R1 was observed sitting in his wheelchair; in the facility living room area. R1 fell/slid out of his wheelchair and began to complain of a headache. Hospice and R1’s responsible party was notified. Facility staff called 911. R1 was admitted to Pomona Valley Medical Center on 12/17/2022 and cleared for discharge on 12/19/2022 back to the facility. Per Pomona Valley Medical Center report, R1’s responsible party agreed to discharge R1 back to the facility and continue hospice care. According to Pomona Valley Medical Center report, R1 was deemed stable on 12/19/2022 and cleared by Neurosurgery to be discharged. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. Although, R1 did suffer a fall and did sustain a minor injury, LPA Ramirez did not observe documentation or interviews to suggest this was as a direct result from staff neglect. 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.

Facility was not feeding resident- It is alleged R1 was not being fed and R1’s responsible party had to bring R1 food. R1 was admitted to the facility on 12/01/2022 and was discharged on 12/29/2022. R1 began hospice care on 12/01/2022. Review of R1’s Medical Assessment dated 11/30/2022, recorded R1’s weight as 125lbs. Per Pomona Valley Medical Center report dated 12/19/2022, R1’s weight was recorded as 54.9 kg (121lbs) on 12/18/2022. Five (5) out of the five (5) staff interviewed deny this allegation. R1 is no longer at the facility and unable to be interviewed. LPA Ramirez made several attempts to contact R1’s responsible party, but as of 11/21/2024, LPA Ramirez has not received a call back. Two (2) out of the two (2) residents interviewed deny this allegation. During facility tour, LPA Ramirez observed staff serving lunch and assisting residents with their meals. LPA Ramirez sufficient food supply in kitchen. 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.

No violations were observed during this investigation. Exit interview was conducted. A copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC9099 (FAS) - (06/04)

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