197609594-1-17-2023-31-AS-NMAN-CN8RPA-20230119121131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609594
Report Date: 09/11/2022
Date Signed: 01/17/2023 02:44:57 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, 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: 64	DATE:	09/11/2022
		UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Veronica Sanchez - Resident Care Coordinator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident's clothes are dirty

Residents clothes are missing

INVESTIGATION FINDINGS:

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

LPA conducted physical plant tour at 9:35 AM, requested copies of facility documents relevant to the investigation and reviewed records between 10:00 AM to 11:30 AM. LPA also interviewed staff and residents between 11:30 AM to 1:30 PM.

Regarding the allegation that Resident's clothes are missing, it was alleged that Resident #1 (R1)'s underwear and clothes are missing, LPA's record review at 10:00 AM, revealed that R1's Power of Attorney (POA) did not declare any personal belongings on the inventory section of R1's Admission Agreement. LPA's observation during physical plant tour at 9:35 AM also revealed that R1 has a walk in closet full of clothes. (continued to 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: 09/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2022

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: 09/11/2022

NARRATIVE

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(continued from LIC 9099)

LPA's interview with two (2) staff revealed that all Memory Care residents' family are advised to label their family members' clothes so as to avoid unintentional mixing with other residents'. Staff also did not receive any complaint or information about R1's missing clothes or items.

Regarding the allegation that Resident's clothes are dirty, it was alleged that R1's clothes are dirty. LPA's observation during today's visit at 9:35 AM, revealed that R1's clothes are clean and tidy. LPA's interview with two (2) staff revealed that all of residents' clothes are being laundered once a week per schedule.

Based on the information gathered during this and prior visit, 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: 09/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2022

LIC9099 (FAS) - (06/04)

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