197609594-6-30-2021-31-AS-NMAN-C9J2SB-20211208163853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609594
Report Date: 06/30/2021
Date Signed: 06/30/2021 04:50:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2021 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20210624141937

FACILITY NAME:	MOUNTVIEW SENIOR LIVING		FACILITY NUMBER:	197609594
ADMINISTRATOR:	CARMY C JEROME		FACILITY TYPE:	740
ADDRESS:	2640 HONOLULU AVE		TELEPHONE:	(818) 248-6737
CITY:	MONTROSE	STATE: CA	ZIP CODE:	91020
CAPACITY:	131	CENSUS:	DATE:	06/30/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Michael Fountain, Operations Specialist		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility staff over-medicated resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted a complaint investigation for the above noted allegation. LPA met with Michael Fountain, Operations Specialist. The purpose of the visit was discussed.
It was reported that facility staff over-medicated Resident 1 (R1) . To investigate the allegation on 6/30/21, LPA conducted staff interviews between 11:00am and 1:00pm. During the course of the investigation, interviews revealed that different nursing agencies are being used to dispense medication to residents and that all medication that is given to residents is documented electronically. Between 1:00pm and 2:00pm, a record review was conducted. LPA reviewed Medication Administration Record (MAR) and R1's physician report. The MAR revealed that R1 was given seizure medication at 8pm on 6/20/21 and Tylenol with codeine was given that same day at 2:15am and at 8:41pm. LPA had the nurse bring out the bubble pack and count the number of pills. The pills dispensed matched with what was documented on the MAR. R1 was taking both medications for twenty days and had no adverse reactions. Based on interviews, record review, and observation, this allegation UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

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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