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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 10/06/2022
Date Signed: 10/06/2022 05:41:05 PM

Document Has Been Signed on 10/06/2022 05:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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: 31DATE:
10/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Laura Hernandez, Administrator TIME COMPLETED:
05:35 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Elizabeth Irra and Noemi Galarza conducted a Case Management-Deficiencies visit due to an immediate health and safety observation made during today's annual inspection. The purpose of the visit was explained to Administrator Laura Hernandez and receptionist staff Daisy Fitter.

At approximately 10:04 AM, LPA Galarza observed cognitively impaired resident (R1) walking by itself onto oncoming traffic on Baseline Road Street. The front door in the administration building was observed to be opened. Staff (S1) was observed running towards the street in an attempt to redirect the resident. However, the resident did not comply and proceeded to cross the major street onto oncoming traffic. The resident walked westbound passed Mountain Avenue. The Claremont Police Department was driving by and assisted with the elopement incident. The resident and staff were not injured. Pictures were taken.

The following documents were obtained:


  • Resident (R1's) file documents [Identification and Emergency Information, Physician's Report, Functional Capability Assessment, and ALW Individual Service Plan].
  • Staff Roster
  • Resident Roster
  • Claremont Police Department DR#: 22126477.

Exit interview was held with Administrator Laura Hernandez. A copy of the report and appeal rights were issued.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2022 05:41 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 10/06/2022 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/07/2022
Section Cited
CCR
87411(a)

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87411(a) Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of:
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Administrator agreed to submit a plan of correction including staff scheduling and supervision of residents. Update resident (R1’s) care plan. In addition, a staff in-service training regarding delayed egress exits, Dementia wandering behavior, methods of redirection, and resident care and supervision shall be conducted by POC due date.
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Based on observation at approximately 10:04 AM resident (R1) eloped out of the facility after exiting the memory care unit through the unlocked front door exit without staff knowledge. Staff did not ensure the front door was closed properly. This posed an immediate safety risk to this resident in care.
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Request Denied
Type A
10/07/2022
Section Cited
CCR87468.2(a)(4)

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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to ... Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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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Administrator agrees to submit a written plan stating how this was corrected, and what was done.

Submit proof of staff training and attach training topics.
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This requirement is not met as evidenced by:
Based on LPA observation resident (R1) eloped to the main street without staff knowledge. This poses an immediate Health and Safety risk to residents in care.
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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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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