198204376-2-9-2023-28-AS-MVAO-CPKTVW-20230303140436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204376
Report Date: 02/09/2023
Date Signed: 02/09/2023 03:52:05 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, 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
02/02/2023 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20230202090838

FACILITY NAME:	MOUNTAIN VIEW COTTAGES - IV		FACILITY NUMBER:	198204376
ADMINISTRATOR:	TRUPTI MODY		FACILITY TYPE:	740
ADDRESS:	21027 COVINA BLVD.		TELEPHONE:	(626) 966-4842
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	6	CENSUS: 2	DATE:	02/09/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Jasbindar Singh, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not treat resident with respect and dignity.
Staff do not follow food menu.
Staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegations listed above today. During today’s visit, LPA met Administrator, Jasbindar Singh. LPA explained the purpose of today's visit regarding the above-mentioned allegations.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #2 (S2); interviews of residents from resident#1 (R1) through resident #3 (R3); reviewed resident#1’s record reviews, and a facility tour. LPA obtained copies of the staff and resident rosters, resident#1’s files and documents with relevant information.

In regard of the allegation, “staff did not treat resident with respect and dignity, it was alleged that staff yell at resident#1, threaten resident#1 and did not treat resident#1 with respect.

(-continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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 28-AS-20230202090838

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOUNTAIN VIEW COTTAGES - IV	FACILITY NUMBER: 198204376
	VISIT DATE: 02/09/2023

NARRATIVE

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The investigation revealed the following: All three (3) residents who were interviewed revealed staff treated residents with respect and dignity. All two (2) staff who were interviewed denied the allegation. Staff interviews revealed facility had a policy and in service training to ensure residents’ right and being treat with respect. Therefore, staff treat residents with respect and dignity at the facility.

In regard of the allegation, “staff do not follow food menu,” it was alleged that facility did not allow food menu to provide meal to residents. The investigation revealed the following: All three (3) residents who were interviewed revealed staff follow food menu to provide food to residents. Per file review, facility had bi-weekly food menu and posted in the kitchen. Three (3) residents interviewed revealed that staff followed food menu and provide various of food. All two (2) staff who were interviewed denied the allegation. LPA tour the kitchen, LPA observed food menu posted in the kitchen and refrigerator had more than two (2) days of perishable food supplies with variety. Therefore, there is not preponderance evidence to prove the facility failed to follow food menu.

In regard of the allegation, “staff mismanaged resident's medication,” it was alleged that facility staff failed to administer resident#1’s medication on 1/31/23. The investigation revealed the following: All three (3) residents who were interviewed revealed staff administer residents' medication properly. All two (2) staff who were interviewed denied the allegation. LPA reviewed residents’ medication records and did not observe any missing medication. Therefore, there is not preponderance evidence to prove the facility staff mismanaged resident's medication.

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 allegations is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

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