198204377-4-6-2021-28-AS-MVAO-BZZUMN-20210412154235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204377
Report Date: 04/05/2021
Date Signed: 04/06/2021 10:31:06 AM

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
08/24/2020 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200824151739

FACILITY NAME:	MOUNTAIN VIEW COTTAGES - I		FACILITY NUMBER:	198204377
ADMINISTRATOR:	PRISCO CASTILLO		FACILITY TYPE:	740
ADDRESS:	1147 CLEGHORN DR.		TELEPHONE:	(909) 861-8508
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 6	DATE:	04/05/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Jasbindar Singh		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not meet residents needs
Staff did not seek timely medical care
Facility is in disrepair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nicole Spencer initiated a subsequent visit to deliver the findings for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Jasbindar Singh, the house manager.

During the course of the investigation, LPA Spencer conducted telephone interviews with the back-up administrator Trupti Mody, staff #1-4 (S1-S4), residents #1-6 (R1-R6) and conducted a video call to tour the physical plant. R2, R3, and R5 could not complete interviews so a total of 3 residents were interviewed. The LPA received copies of the staff roster, resident roster and for resident # 1 (R1): physician orders for medication "Northea," MAR chart, Needs and services plan, discharge papers from hospital regarding fall on 7/19/20, and unusual incident report. See LIC9099-C for continuation of this narrative.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

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-20200824151739

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 - I	FACILITY NUMBER: 198204377
	VISIT DATE: 04/05/2021

NARRATIVE

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The investigation revealed the following:
Staff did not meet residents needs
R1 stated that staff do not meet resident needs outside of normal working hours. Interviews with staff revealed that there are 2 live-in staff and and 2 non-live in staff. All staff stated that the staff provide care even during non-working hours to meet residents needs. S3, house manager, stated that the live-in staff work 2 hours of overnight shift in addition to their day shift. 2 out of 3 residents interviewed stated that staff meet residents needs and they have observed staff helping at all hours.
Staff did not seek timely medical care
Interviews with back-up administrator Trupti Mody revealed that on 7/19/20, R1 was found by S2 collapsed on the floor at approximately 6:00 a.m. She stated that paramedics were called and R1 was admitted to the hospital by 7:03 a.m. S2 stated that he discovered R1 on the floor, asked him if he was okay, and helped him to the bed. He told S1 to call 911 shortly after helping R1 back to the bed because he noticed bleeding from the resident's forehead. A review of the incident report from the fall dated 7/19/20 confirmed that S2 found R1 on the floor with blood on his head. S2 helped R1 into bed and asked if he needed to go to the hospital. R1 said yes so S1 called 911. Paramedics arrived and transported him to Pomona Valley Hospital. A review of the discharge papers shows that he was discharged from the hospital at 10:43 a.m.
Facility is in disrepair
During the observation, LPA observed that all toilets in the facility flushed with toilet paper without overflowing. 2 out of 3 residents interviewed stated that the toilet is working. S3, house manager, stated that the toilets are working but they did have a plumbing problem that was fixed a few months prior. She stated that they have not had issues with the toilets since then. S1 and S2 stated that they don't give toilet paper to residents because some have dementia and will fill the toilets with toilet paper, so they ask residents not to put the toilet paper in the toilet and instead put it in the trash. They stated that the toilets work but that they do this as a preventative measure. Back-up administrator Trupti Mody stated that residents can put toilet paper in the toilets as long as it's not too much to cause overflowing.
Based upon physical plant observation, interviews conducted, and documents reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) areUnsubstantiated.
A telephonic exit interview was conducted with house manager. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

LIC9099 (FAS) - (06/04)

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