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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801605
Report Date: 09/12/2024
Date Signed: 09/12/2024 10:35:52 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2023 and conducted by Evaluator Sanjay Vaid
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230907141335
FACILITY NAME:MOUNTAIN VIEW CENTERFACILITY NUMBER:
197801605
ADMINISTRATOR:LAURA HERNANDEZFACILITY TYPE:
740
ADDRESS:715 WEST BASELINE ROADTELEPHONE:
(909) 626-6633
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:40CENSUS: 36DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Administrator, Laura HernandezTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Due to staff neglect, resident fell resulting in injury.
Staff did not seek timely medical care for resident
Staff did not follow resident's fall plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsequent complaint visit regarding the allegations listed above to deliver complaint investigation findings. Conducted physical tour with Daisy Fitter, no health and safety issue were noted. Laura Hernandez arrived shortly after.

On 09/08/2023, Program Analyst (LPA) V. Maldonado made an unannounced initial visit to the facility to conduct a Health and Safety check inspection, in response to the above-mentioned allegations. LPA met with staff Elvira Cortez and explained the purpose for the visit. Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas with assistance of staff Daisy Fitter, and obtained the following documents for Residents# 1-4 (R1-R4): Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA did not observe any immediate health and/or safety concerns. On 08/20/2024. Licensing Program Analyst (LPA) S Vaid made an unannounced subsequent visit to the facility to conduct further investigations, in response to the above-mentioned allegations. LPA met with the staff Daisy Fitter and explained the purpose for the visit. Continued on 9099C.....
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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 4
Control Number 28-AS-20230907141335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 09/12/2024
NARRATIVE
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 Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas. Requested and obtained the following documents for Residents# 3: Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA conducted interviews with four (4) staff members and two (2) residents. LPA observed resident rooms to be free of hazards. Investigation Branch, Investigator Olivia Spindola conducted further investigation.

Regarding the allegation: (1) Due to staff neglect, residents fell resulting in injury. (2) Staff did not seek timely medical attention for the resident. (3) Staff did not follow the resident’s fall plan. Four (4) out of four (4) staff denied the allegation. Two out of (2) residents could not corroborate the allegation. It is alleged that resident R3 had an unwitnessed fall and sustained injuries in the early hours of the morning, on 09/01/2023. Caregivers discovered R3 on the floor near the bed. Staff put R3 back in bed and did not notify the Facility Administrator, did not make assessment of the fall. According to staff statements (investigated by Spindola), morning caregiver mentioned R3 was feeling very sore and complained of pain. Caregiver(s) did not apply fall care assessment to resident. After breakfast, upon rising from dining seat R3 screamed in pain, was sent to Pomona Valley Hospital for emergency medical care. Investigator Olivia Spindola conducted further investigation. R3 was diagnosed at Pomona Valley Hospital with multiple fractured left ribs and punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The Individual Service Plan dated 02/16/2023, received by Mountain View facility, noted that R3 was totally dependent, need assistive devices; needs walker and wheelchair, shower chair. Section C page 9 of the assessment tool indicates resident is at risk for falls. Section C page 24 identifies risks to personal safety; potential for falls, unsteady gait and fall history. Residential appraisal dated 03/17/2023, indicates under services needed: balance is off, very wobbly. Bathing: needs to be monitored so they do not fall. Functional Capability Assessment dated 03/17/2023 indicates balance is off. 06/03/2023, R3 had a fall in the patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off their bed and hit their head. On the early morning hours of 09/01/2023, caregiver found R3 on the floor near their bed, and put R3 back into bed without assessing them. Overnight shift caregivers did not inform the facility administrator nor seeking medical attention and failed to render R3 services needed, due to fall plan not being followed as shown in the documents reviewed.
Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230907141335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOUNTAIN VIEW CENTER
FACILITY NUMBER: 197801605
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/12/2024
Section Cited
CCR
87458.2(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities.
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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This requirement was not met evidenced by:
Based on record review, the findings indicate that on 09/01/2023, Facility person(s) responsible for giving clear instructions and explanations of R3’s Fall Care Plan to the facility staff and to R3’s caregivers, resulting in R3’s injuries sustained.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 28-AS-20230907141335
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOUNTAIN VIEW CENTER
FACILITY NUMBER: 197801605
VISIT DATE: 09/12/2024
NARRATIVE
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***An immediate Civil Penalty of $500.00 is being issued today, due to Resident # 3, (1) Due to staff neglect, residents fell resulting in injury. (2) Staff did not seek timely medical attention for the resident. (3) Staff did not follow the resident’s fall plan. Refer to LIC 421IM***

The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect.

Exit interview was conducted with Laura Hernandez and a copy of this report, LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Sanjay Vaid
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4