197609594-10-12-2022-31-AS-NMAN-CN8RP8-20230119121131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609594
Report Date: 10/09/2022
Date Signed: 10/12/2022 08:20:46 AM

Unsubstantiated

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
05/19/2021 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20210519142527

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: 65	DATE:	10/09/2022
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Veronica Sanchez - Resident Care Coordinator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Residents hygiene needs are not being met

Staff did not seek medical attention for resident in care

Staff have not given resident medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent visit at this facility to further investigate the above allegations. LPA met with Resident Care Coordinator Veronica Sanchez and explained the reason for the visit.

LPA conducted physical plant tour at 9:34 AM, requested copies of facility documents relevant to the investigation at 10:02 AM, reviewed records between 10:15 to 12:00 PM and interviewed staff and 12:10 PM to 2:00 PM.

Regarding the allegation that residents hygiene needs are not being met, it was alleged that the Resident #1 (R1)'s hair was dirty and R1's teeth were dirty like they had not been washed and brushed for a while. LPA's record review revealed that R1's was showered and body inspected as scheduled unless R1 refused.

(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2022

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 31-AS-20210519142527

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MOUNTVIEW SENIOR LIVING	FACILITY NUMBER: 197609594
	VISIT DATE: 10/09/2022

NARRATIVE

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(continued from LIC 9099)

LPA's interview with three (3) memory care staff today between 12:10 PM to 2:00 PM also revealed that R1 was being attend to like other residents in memory care unit and clean and groomed every morning before breakfast, including but not limited to dressing, brushing teeth, showering and change of diapers. LPA's observation during physical plant tour today at 9:34 AM at the memory care unit also revealed that the residents were neatly dressed and well groomed.

Regarding the allegation that staff did not seek medical attention for resident in care, it was alleged that R1 was found to have a toe fungal infection and did not see the facility Podiatrist. LPA's record review today at around 10:15 AM revealed that there was a communication between the facility and the facility Podiatrist on 02/25/21 requesting the latter to see R1. R1 was issued new medication order on 03/11/21 for R1's toenail but was only seen by the Podiatrist on 05/13/21 at the facility due to the doctor's availability. There were also communication with other doctor regarding R1's foot condition on 03/31/21 and 04/06/21.

Regarding the allegation that staff have not given resident medication, it was alleged that R1 was not given toenail medication on 05/10/21 as ordered by the physician. LPA record review today at around 11:25 AM revealed that the toenail medication was prescribed to be applied at bedtime and R1's medication administration record (MAR) review revealed that the medication was applied every night as prescribed.

Based on the information gathered during this and prior visits, the allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2022

LIC9099 (FAS) - (06/04)

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