198204372-11-15-2023-28-AS-TVAO-CYRPD5-20231222101255

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204372
Report Date: 11/15/2023
Date Signed: 11/15/2023 01:59:20 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/08/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231108132115

FACILITY NAME:	MOUNTAIN VIEW COTTAGES -II		FACILITY NUMBER:	198204372
ADMINISTRATOR:	TRUPTI MODY		FACILITY TYPE:	740
ADDRESS:	1000 PARK SPRING LANE		TELEPHONE:	(909) 860-6558
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	4	CENSUS: 3	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Eva Nainggolan, Staff		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff flicked resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the above allegation. LPA arrived unannounced and met with Staff, Eva Nainggolan. Administrator, Trupti Mody, could not be present at the facility, therefore, the purpose of the visit was explained via telephone.

LPA obtained a copy of the staff and resident rosters. Interviews were held with the Administrator via telephone, 5 Staff (Staff #1 - #5), and 3 Residents (Resident #1 - #3).

Allegation – Facility staff flicked a resident in care. It is alleged that Staff #1 (S-1) flicked Resident #1 (R-1) on the forehead. Administrator stated an interval investigation was conducted and S-1 admitted to flicking R-1 on the head. During the visit today, LPA interviewed Staff and Residents. S-1 admitted to flicking R-1 by the ear and stated it was a one time occurrence. S-1 indicated the flick was not hard as staff was doing so playfully.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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 5

Control Number 28-AS-20231108132115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 COTTAGES -II	FACILITY NUMBER: 198204372
	VISIT DATE: 11/15/2023

NARRATIVE

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LPA attempted to interview R-1 regarding this incident but was unsuccessful. LPA interviewed the other 2 residents, of which one witnessed S-1 flicking R-1 on the head while sitting at the dining table.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with the administrator via telephone. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20231108132115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 COTTAGES -II	FACILITY NUMBER: 198204372
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/16/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator shall conduct an in-service training with staff regarding personal rights by POC due date 11/16/23.
	8 9 10 11 12 13 14	Based on interviews, staff flicked resident on the head which posed an immediate personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/08/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231108132115

FACILITY NAME:	MOUNTAIN VIEW COTTAGES -II		FACILITY NUMBER:	198204372
ADMINISTRATOR:	TRUPTI MODY		FACILITY TYPE:	740
ADDRESS:	1000 PARK SPRING LANE		TELEPHONE:	(909) 860-6558
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	4	CENSUS: 3	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Eva Nainggolan, Staff		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Facility staff hit resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
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12
13

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the above allegation. LPA arrived unannounced and met with Staff, Eva Nainggolan. Administrator, Trupti Mody, could not be present at the facility, therefore, the purpose of the visit was explained via telephone.

LPA obtained a copy of the staff and resident rosters. Interviews were held with the Administrator via telephone, 5 Staff (Staff #1 - #5), and 3 Residents (Resident #1 - #3).

Allegation – Facility staff hit resident in care. It is alleged that Staff #1 (S-1) smacked the back of Resident #1’s (R-1) head. LPA interviewed the Administrator and Staff. The administrator stated an internal investigation was conducted and did not find supporting evidence of alleged staff hitting a resident. Administrator also stated that the police officers came in response to the allegation and did not suspect any abuse from staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20231108132115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 COTTAGES -II	FACILITY NUMBER: 198204372
	VISIT DATE: 11/15/2023

NARRATIVE

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During the visit today, LPA interviewed (S-1) who denied smacking R-1 on the head. Other staff did not witness S-1 hitting any residents. They stated they treat residents with respect and would not hit a resident. R-1 was interviewed and responded yes to staff hitting resident. However, R-1 could not provide any details regarding incident. Additional residents interviewed have not observed S-1 or any other staff hitting another resident. LPA did not observe any bruises or marks on R-1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with staff Cherry Serame. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5