198600002-12-21-2021-28-AS-WSHO-C9WUGD-20211221143411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198600002
Report Date: 11/09/2021
Date Signed: 12/21/2021 01:22:21 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
10/11/2019 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20191011104430

FACILITY NAME:	MOUNTAIN VIEW CARE		FACILITY NUMBER:	198600002
ADMINISTRATOR:	CAROLINE TAN		FACILITY TYPE:	735
ADDRESS:	2622 MOUNTAIN VIEW ROAD		TELEPHONE:	(626) 448-1682
CITY:	EL MONTE	STATE: CA	ZIP CODE:	91733
CAPACITY:	83	CENSUS: 81	DATE:	11/09/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Caroline Tan		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Client sustained an unexplained head injury resulting in hospitalization

INVESTIGATION FINDINGS:

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The purpose of this report is to correct the date of the report. LPA inadvertently had previous report listed as 11/09/2020 and it should have been 11/09/2021. LPA Trueman amended LIC9099 on 12/21/21 to remove confidential names on the report. LPA Trueman made revisions on 12/21/21 which does not change the finidngs of this investigation. Signatures are obtained for the amended reports

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Caroline Tan and explained the reason for the visit. The purpose of the visit is to deliver findings from the original complaint dated 10/11/2019.

The initial visit was a Health and Safety Check conducted on 10/14/2019. The Investigations Branch (IB) from the California Department of Social Services conducted an investigation that was completed on 1/17/2020. The investigation was conducted by Investigator Tiffany Brunelli which included interviews with facility staff, residents, Resident 1's psychiatrist and treating physician from hospital.

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

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-20191011104430

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 CARE	FACILITY NUMBER: 198600002
	VISIT DATE: 11/09/2021

NARRATIVE

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During the course of the investigation it revealed that on 10/9/2019 at 0800 or 0830 hours, Resident 1 told Staff that he hit Resident 2 because he asked for a cigarette. Resident 1 confessed to law enforcement Officer on 10/9/2019 at 1631 hours that Resident 2 asked for a cigarette and that he punched Resident 2 in the mouth one time with his right wrist. Resident 3 who was interviewed on 11/13/2019 at 1240 hours stated that she saw Resident 1 hit someone and he fell down in the parking lot. This resulted in Resident 2 who sustained a head trauma. On 10/9/2019 that same morning, Resident 1 had a fight with his roommate. Resident 1's psychiatrist stated on the day of the incident in the morning of 10/9/2019, Resident 1 admitted to using meth and cannabis since last week and observed him at 1130 hours on the day of the incident buying drugs.

Incident Report dated 8/6/2019 indicated that Resident 1 hit another resident. Warning letter dated 4/9/2018 indicated Resident 1 hit another resident. Incident Report dated 4/8/2018 indicated Resident 1 punched another resident in the face for no reason.

The facility failed to properly evict or find better placement for Resident 1 to avoid incidents. Based on Resident 1's history of hitting residents, recent drug and alcohol use, on date of incident fighting with roommate, observed drinking a beer and admitting to using meth the day before the incident and the seriousness of life threatening injuries sustained by Resident 2 the allegation of lack of care and supervision is deemed Substantiated.

Based on the Investigations Branch observations and interviews which were conducted record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099 D.

Immediate $500 Civil penalty issued for violation that the department determined resulted in the injury or illness of a person in care.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20191011104430

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 CARE	FACILITY NUMBER: 198600002
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/09/2021 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Based on interviews conducted and file review licensee failed to provide care and supervision necessary with Resident 1	1 2 3 4 5 6 7	Administrator to provide training on providing necessary care and supervision to meet client's needs at all times which includes dealing with and reporting aggressive resident behaviors. Signed log to be submitted to licensing by POC due date.
	8 9 10 11 12 13 14	hitting Resident 2 resulting in a head injury which became an Immediate Health and Safety risk to Resident's in care. Immediate Civil Penalty assessed $500.	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.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

LIC9099 (FAS) - (06/04)

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