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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204376
Report Date: 12/12/2023
Date Signed: 12/12/2023 01:10:31 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, 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
01/28/2021 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210128160641
FACILITY NAME:MOUNTAIN VIEW COTTAGES - IVFACILITY NUMBER:
198204376
ADMINISTRATOR:TRUPTI MODYFACILITY TYPE:
740
ADDRESS:21027 COVINA BLVD.TELEPHONE:
(626) 966-4842
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 4DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jasbindar Singh- AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Resident suffered a fall resulting in a fracture.
Staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado conducted an unannounced subsequent complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Administrator, Jasbindar Singh, and explained the purpose for the visit.

On 01/29/21, Licensing Program Analyst (LPA) Tao conducted the initial complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted via tele-conference with Administrator, Jasbindar Singh. During the virtual visit, LPA Tao conducted a health and safety check and requested a copy of the Staff and Resident roster. LPA Tao virtually toured the facility via Facetime with Administrator and observed that the facility is clean and in good repair. LPA observed nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. LPA Tao observed wash basins, showers/bathtubs and toilets were operable and did not observe any immediate health and safety concerns.
(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
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 7
Control Number 28-AS-20210128160641
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: 12/12/2023
NARRATIVE
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The investigation of the above-mentioned allegations was conducted by the licensing agency's Investigation Bureau. The investigation was conducted by the assigned Investigator, Dennis Seng and consisted of the following: Interviews conducted with Administrator (S1) and Staff #2 - #3 (S2 & S3), Residents #1 - #4 (R1, R2, R3 & R4), Witnesses #1 & #2 (W1 & W2), and Staff at other agencies (W3 & W4), including Adult Protective Services and Long-Term Care Ombudsman program. Investigator Seng also reviewed R1's facility file/documentation, including incident reports dated 10/23/20, and medical records dated 11/03/20 and 11/06/20. The investigation revealed the following:
Regarding allegation: Resident suffered a fall resulting in a fracture.
It was alleged that R1, who was deemed a fall risk, fell over a raised threshold in the doorway while ambulating, due to staff failing to assist R1. Interviews with (4) of (4) staff indicated that R1 fell in the facility and that R1’s family did not want the facility staff to call 911. (3) of (4) residents interviewed could not corroborate the allegations. Per incident report dated 10/23/20, it was indicated that R1 had a fall at the facility, was helped back into bed, and responsible parties were notified. Interviews with W1-W2 revealed that on 10/23/20, R1 called W1-W2 regarding the fall and stated to be in pain and asked to go to the hospital. However, facility staff informed W1-W2 that staff were unable to arrange R1’s transportation. Interviews with W3-W4 revealed that R1 fell in the facility on 10/23/20 and was not seen by a medical professional until early November 2020. Review of R1's file revealed that R1 was a fall risk as indicated on R1’s Individual Service Plan, dated 09/17/20. Therefore, based on the investigation, the facility failed to provide resident with adequate care and supervision, which resulted in R1 falling and sustaining an injury.
Regarding Allegation: Staff did not seek medical attention in a timely manner.
It was alleged that after R1 fell at the facility while being a fall risk, R1 expressed pain to staff and requested an x-ray be taken; However, staff did not obtain medical treatment for the resident until a week later. During the investigation, Investigator Seng reviewed R1’s facility file/documentation, including incident reports dated 10/23/20, and medical reports dated 11/03/20 and 11/06/20. Per the incident report dated 10/23/20, R1 fell over a raised threshold in doorway at the facility while walking into R1’s room. R1 informed S3-S4 that R1 was in pain and wanted to go to the hospital to get an x-ray. Administrator and staff spoke with W1-W2, and per Administrator, W1 and W2 requested R1 not be sent out for medical treatment. Per medical records review, it was discovered that R1 did not receive medical treatment until 11/03/20, which was (11) days after the fall occurred 10/23/20. X-rays taken on 11/06/20 revealed that R1 sustained a fracture to the right hand. Therefore, based on the investigation, staff failed to seek timely medical attention for R1, after R1 fell at the facility and expressed pain to staff, which resulted in a fracture to R1's right hand.
(Report continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20210128160641
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: 12/12/2023
NARRATIVE
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Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegations are found to be Substantiated.

Per California Code of Regulations, Title 22, Division 6, and Chapter 8, deficiencies will be cited on the attached LIC9099-D.

An immediate $500 civil penalty is being issued during today's visit due to the lack of care and supervision that occurred on 10/23/20 when R1 fell in the facility and sustained a fractured right hand.

“The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).“

An exit interview was conducted and a copy of this report, along with appeal rights, were discussed and provided to Administrator, Jasbindar Singh.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 28-AS-20210128160641
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General
(a) 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 as evidenced by:
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Licensee will submit a plan in writing on how facility staff will ensure to meet the needs of all residents including proper care and supervision, per their Individual Needs and Services Plans. Written plan to be submitted to LPA via email by POC due date.
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Based on interviews and records review, facility staff failed to provide necessary supervision for (1) of (4) residents who fell at the facility and resulted in a fractured hand, which poses an immediate Health, Safety, or Personal rights risk to persons in care.
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Type B
12/22/2023
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care
(g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...
This requirement was not met as evidenced by:
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Licensee will conduct in-service training for all facilty staff on obtaining proper medical care for residents as needed/required. Copy of training material and sign-in sheet to be sent to LPA via email by POC due date.
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Based on interviews and records review, facility staff failed to seek timely medical attention for (1) of (4) residents, after falling in the facility and sustaining a fracture to the right hand, which poses a potential Health, Safety, or Personal Rights risk to persons 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
01/28/2021 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20210128160641

FACILITY NAME:MOUNTAIN VIEW COTTAGES - IVFACILITY NUMBER:
198204376
ADMINISTRATOR:TRUPTI MODYFACILITY TYPE:
740
ADDRESS:21027 COVINA BLVD.TELEPHONE:
(626) 966-4842
CITY:COVINASTATE: CAZIP CODE:
91724
CAPACITY:6CENSUS: 4DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jasbindar Singh- AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
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Facility is in disrepair.
Staff did not provide an adequate amount of food to resident.
Resident was denied food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Administrator, Jasbindar Singh, and explained the purpose for the visit.

On 01/29/21, Licensing Program Analyst (LPA) Tao conducted the initial complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted via tele-conference with Administrator, Jasbindar Singh. During the virtual visit, LPA Tao conducted a health and safety check and requested a copy of the Staff and Resident roster. LPA Tao virtually toured the facility via Facetime with Administrator and observed that the facility is clean and in good repair. LPA observed nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. LPA Tao observed wash basins, showers/bathtubs and toilets were operable and did not observe any immediate health and safety concerns.
(Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20210128160641
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: 12/12/2023
NARRATIVE
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During today's visit, LPA Maldonado obtained a copy of the resident and staff rosters, Facesheet and Physician's Reports for Residents# 2, and #5-7 (R2, and R5-R7), and conducted a tour of the physical plant with assistance of Administrator Singh. Interviews were also conducted with Staff# 1 and #4 (S1 and S4), and attempted interviews with R2, and R5-R7.

The investigation revealed the following:
Regarding allegation: Facility is in disrepair.
It was alleged that during the winter months of 2020, the facility heater was in disrepair for one month and delays in plumbing issues on a single toilet shared by (5) residents. Per interviews with staff, S1 stated that although the central heating system was not operating properly for a short period of time, individual heater units were brought in the home and each resident had one placed in their room. S1 also stated that although they did have a plumbing issue on Thanksgiving Day of 2020 in one restroom, the residents were able to use the other restroom in the home, as needed. S4 states no work receipt is available, but recalls the incident and stated that a plumber came the following day to repair it, as it was difficult to have anyone come out on Thanksgiving Day. S4 could not corroborate the allegation as S4 states to not have worked at the facility at the time of the alleged. (4) of (4) residents could not corroborate the allegation. During the tour of the physical plant, LPA observed the thermostat temperature set at 82*F inside the home. LPA observed all resident rooms and common areas to have heat vents, and observed them to be operating properly. LPA also inspected the (2) bathrooms in the home and observed them to be clean, sanitary, and were operable during the visit.
Regarding allegation: Staff did not provide an adequate amount of food to resident.
It was alleged that R1 did not receive enough food during meals and was given (4) yogurts for Thanksgiving dinner. (2) of (2) staff interviewed denied the allegations and stated that there is always sufficient amount of food/groceries available at the facility for residents. Staff stated that residents are provided with (3) meals and (3) snacks of their choice every day. (1) of (4) residents interviewed denied the allegation and stated that sufficient food is given during meals and snacks are always available. LPA attempted interviews with (3) of (4) residents- they could not corroborate the allegation. During the tour of the physical plant, LPA inspected the food supplies and observed a sufficient amount of perishable and non-perishable foods available for the number of residents in care, which included milk, eggs, vegetables, meats, cereals, cookies, oatmeal, pudding cups, and fresh fruits.

(Report continued on LIC9099-C...)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20210128160641
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: 12/12/2023
NARRATIVE
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Regarding allegation: Resident was denied food.
It was alleged that facility staff denied R1 more food, after not receiving enough food to satisfy R1's hunger. (2) of (2) staff interviewed denied the allegation and stated that there is always sufficient food at the facility to give to residents if they wish to have more. Staff also stated that the residents are allowed to take whatever they wish at any time from the kitchen or pantry. They may sometimes request it directly from staff and staff will assist the residents with it. Staff stated that residents are provided with (3) meals and (3) snacks of their choice, per day. (1) of (4) residents interviewed denied the allegation and stated that all residents are given whatever amount of food they want. LPA attempted interviews with (3) of (4) residents- they could not corroborate the allegation. During the tour of the physical plant, LPA inspected the food supplies and observed a sufficient amount of perishable and non-perishable foods available for the number of residents in care, which included milk, eggs, vegetables, meats, cereals, cookies, oatmeal, pudding cups, and fresh fruits. LPA did not observe any food items hidden, locked, or inaccessible to residents in care.

Based on the LPA's record review, interviews, and observations, the investigation revealed: 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 Administrator, Jasbindar Singh, and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7