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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366409605
Report Date: 07/28/2023
Date Signed: 07/28/2023 12:23:02 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2023 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230721164908
FACILITY NAME:MOUNTAIN VIEW COTTAGES-VIFACILITY NUMBER:
366409605
ADMINISTRATOR:MODY, TRUPTIFACILITY TYPE:
740
ADDRESS:6619 AMBERWOOD DRTELEPHONE:
(909) 980-4028
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: 4DATE:
07/28/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Trupti Mody - AdministratorTIME COMPLETED:
12:28 PM
ALLEGATION(S):
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Staff yells at residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to commence the complaint investigation of and deliver findings on the above allegations. LPA met with direct support provider (DSP) Octavia Mcvea who was informed of the purpose of today’s visit. The investigation consisted of witness, staff, and resident interviews and records review.

The allegation is Staff yells at residents in care. It is alleges that staff verbally abuse residents on a regular basis. Interviews with witness and staff deny that staff yell at residents and these interactions are between facility staff, not towards residents. Resident interviews deny that staff yell at them. This allegation is therefore UNSUBSTANTIATED.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. This report was reviewed with administrator Trupti Mody.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2023 and conducted by Evaluator Anna Bueno
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230721164908

FACILITY NAME:MOUNTAIN VIEW COTTAGES-VIFACILITY NUMBER:
366409605
ADMINISTRATOR:MODY, TRUPTIFACILITY TYPE:
740
ADDRESS:6619 AMBERWOOD DRTELEPHONE:
(909) 980-4028
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: 4DATE:
07/28/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Trupti Mody - AdministratorTIME COMPLETED:
12:28 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff speaks inappropriately to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to commence the complaint investigation of and deliver findings on the above allegations. LPA met with direct support provider (DSP) Octavia Mcvea who was informed of the purpose of today’s visit. The investigation consisted of witness, staff, and resident interviews and records review.

The allegation is Staff speaks inappropriately to residents in care. It is alleged that staff make inappropriate comments in the presence of residents. Interviews with witness and staff acknowledged that Staff 1 (S1) was observed making comments towards other staff. Interviews with staff and residents confirm that S1 would speak loudly to residents and other staff. Interviews further reveal that S1 would instruct residents that S1 is the authority in the home. This poses a potential health and safety risk to client in care. Refer to LIC809-D for deficiency cited.

Based on the information obtained, this agency has substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. An exit interview was conducted and a copy of this report, LIC809-D, and appeal rights were provided to Administrator Mody.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
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 3
Control Number 56-AS-20230721164908
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MOUNTAIN VIEW COTTAGES-VI
FACILITY NUMBER: 366409605
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities -- (a) Residents in all RCFE shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement was not met as evidenced by:
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Licensee provide S1 with training or information on resident personal rights and corrective action. Licensee shall submit POC to the Department no later than the end of the POC date.
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Based on interviews with staff, wtiness, and residents, S1 was observed to speak loudly at residents and claim that they are the authority in this home to be followed.
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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.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3