197609594-9-15-2022-31-AS-NMAN-CN8RP9-20230119121131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609594
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:50:12 PM

Substantiated

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:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Ernest Lewis - Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not follow Dr. orders

Medications were accessible to resident in care

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 Executive Director Ernest Lewis 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 12:00 PM. LPA also interviewed staff between 12:15 AM to 1:30 PM.

Regarding the allegation that the staff did not follow orders, it was alleged that Resident #1 (R1) resident supposed to have one (1) patch to put on his back daily but was found to have two (2) patches on R1's chest on 05/03/21. LPA's record review today between 10:00 AM to 12:00 PM, revealed that R1 was prescribed one (1) patch for every twenty four (24) hours. Photo evidence provided by the witness revealed that R1 had two (2) patches on R1's chest. (continued on LIC 9099-C)

Substantiated

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: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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: 09/15/2022

NARRATIVE

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(continued from LIC 9099)

Further record review also revealed that communication between the facility and R1's physician confirmed that R1 had two (2) patches on chest on 04/28/21 and staff failed to remove the old patch before applying a new one.

Regarding the allegation that Medications were accessible to resident in care, it was alleged that prescription medication was left in R1's room and accessible to R1. LPA's record review today between 10:00 AM to 12:00 PM revealed that the photo evidence provided by the witness had clearly shown that the prescription medication was in R1's room and accessible to the resident.

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

Citation issued. Appeal rights discussed and given. 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: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/16/2022 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director agreed to re train all the medication technician and will provide proof of training to CCL on or before the POC date.
	8 9 10 11 12 13 14	Based on LPA record review the licensee did not abide by R1's physician's order. This poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
Type A 09/16/2022 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director agreed to do a daily sweep to all memory care residents and train all staff regarding prohibited items on dementia residents and will submit proof of training and daily log to CCL on or before the POC date.
	8 9 10 11 12 13 14	Based on LPA record review, licensee failed to keep the prescription medication in central medication storage and accessible to R1. This poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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