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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601602
Report Date: 02/21/2023
Date Signed: 02/21/2023 12:56:57 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
02/13/2023 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20230213130816
FACILITY NAME:MONTEVISTA GARDENFACILITY NUMBER:
198601602
ADMINISTRATOR:LAURA MARCELA AGUILARFACILITY TYPE:
740
ADDRESS:1812 MONTE VISTA ST.TELEPHONE:
(626) 568-2793
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 3DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Laura Aguilar - Administrator TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility did not report injury to proper agencies
Facility failed to provide refund after the death of the resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Marcelino Aguilar - caregiver and explained the reason for the visit. Laura Aguilar Administrator arrived 5 minutes later.

The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster. LPA interview administrator(S1) and reviewed Resident #1(R1)'s file, requested copies of admission agreement dated 8/30/21, invoices for November/December 2022 and January 2023, emergency and identification information sheet, physician's report dated 8/23/21, power of attorney documents for R1, LPA interviewed staff #2(S2), and staff #3(S3) over the phone. LPA attempted to interview 3 residents.

The investigation revealed the following: Regarding allegation: Facility did not report injury to proper agencies. It is alleged facility staff did not reported injury to community care licensing division (CCLD).
(CONTINUED LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
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-20230213130816
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: MONTEVISTA GARDEN
FACILITY NUMBER: 198601602
VISIT DATE: 02/21/2023
NARRATIVE
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During resident file review, no incident report, death report, or hospice notification were observed for R1. During interview with administrator Laura Aguilar stated to not have submitted an incident report, death report, or hospice notice for R1 to the department. LPA reviewed submitted documents to the department prior to the visit and did not find incident report or death report.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding allegation: Facility failed to provide refund after the death of the resident. It is alleged facility has a no refund for monthly fees after the death of a resident. During file review, admission agreement was observed to have been signed and initial on 8/30/21. R1 was admitted to the facility on 8/30/21 and passed away on 1/12/23. Invoice provided to the R1's family representative fees were charge for the month of January 2023. Interview with administrator revealed the facility did not provide a refund after the death R1. Per administrator family representative remove all R1's personal belongings on 1/14/23.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

Exit interview was conducted with Laura Aguilar Administrator and a copy of this report, LIC 9099D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 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
02/13/2023 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20230213130816

FACILITY NAME:MONTEVISTA GARDENFACILITY NUMBER:
198601602
ADMINISTRATOR:LAURA MARCELA AGUILARFACILITY TYPE:
740
ADDRESS:1812 MONTE VISTA ST.TELEPHONE:
(626) 568-2793
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY:6CENSUS: 3DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Laura Aguilar - Administrator TIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
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3
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9
Facility did not reimburse responsible party fees for incontinence care supplies
Resident sustained an injury while in care due to lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA met with Marcelino Aguilar - caregiver and explained the reason for the visit. Laura Aguilar Administrator arrived 5 minutes later.

The investigation consisted of the following: LPA Flores requested a copy of staff/resident roster. LPA interview administrator(S1) and reviewed Resident #1(R1)'s file, requested copies of admission agreement dated 8/30/21, invoices for November/December 2022 and January 2023, emergency and identification information sheet, physician's report dated 8/23/21, power of attorney documents for R1, LPA interviewed staff #2(S2), and staff #3(S3) over the phone. LPA attempted to interview 3 residents.

The investigation revealed the following: Regarding allegation: Facility did not reimburse responsible party fees for incontinence care supplies. It is alleged family representative requested a reimbursement for the charge of unused diapers as 4 boxes were purchase and only a box could have been used during that time.
(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230213130816
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: MONTEVISTA GARDEN
FACILITY NUMBER: 198601602
VISIT DATE: 02/21/2023
NARRATIVE
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Interview with residents revealed 1 out of 3 residents stated not to have incontinence needs and LPA was unable to interview 2 out of 3 residents due to cognitive skills. Interviews conducted with staff revealed, 3 out of 3 staff stated R1 was change between 4-6 times throughout the day and 2 out of the 3 staff stated R1 was changed between 5-6 times at night. Per administrator diapers were kept in residents room and if there were any diapers left they would have been in room for family to pick up. Document review revealed facility does not maintain a changing log for residents and no additional notes on incontinence care were observed. Invoice for January 2023 notes a charge of $76.00 for 4 packs of 18 briefs each.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBSTANTIATED.

Regarding allegation: Resident sustained an injury while in care due to lack of supervision. It is alleged on 12/30/22 R1 sustained a broke wrist while in. Interview with residents revealed 1 out of 3 residents stated facility's care and supervision is proper to resident's needs and LPA was unable to interview 2 out of 3 residents due to cognitive skills. Interviews with staff revealed, 3 out of 3 staff stated a staff was usually with R1 when moving around the facility and that on 12/30/22 R1 per usual was moving around with walker, after finishing breakfast R1 got up to sit on reclining chair with S3 assisting her. Upon attempting to seat R1 loss balance and arm slipped by chair's arm rest. At the time of the incident R1 did not complaint of pain, there were no marks, or cuts visible. In the evening staff notice a bruise and notify administrator immediately. Administrator followed to notify family representative, who requested R1 be taken to urgent care in the morning.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBSTANTIATED

Exit interview was conducted with Laura Aguilar administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230213130816
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: MONTEVISTA GARDEN
FACILITY NUMBER: 198601602
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2023
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...: (1) A written report shall be submitted...within seven days of the occurrence of any of the events specified in (A) through (D) below...

This requirement is not met as evidence by:
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Administrator will submit incident report for 12/30/22, and death report for 1/12/23, and certify in LIC 9098 that will ensure all incident reports and death reports are submitted timely to the department by POC due date 2/28/23.
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Based on document review Licensee did not ensure an incident report, or death report was submitted to the department which poses a potential health, safety, or personal rights risk to the persons in care.
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Type B
02/28/2023
Section Cited
CCR
87507(g)(5)(C)
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87507 Admission Agreements: (g) Admission agreements ...: (5) Refund conditions. (c)A refund of any fees paid in advance.. after the... personal property has been removed from the facility shall be issued... within 15 days after the personal property is removed.
This requirement is not met as evidence by:
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Administrator will provide a refund to R1's responsible party for fees after 1/14/23 for a total of 17 days per prorate and will submit a copy of refund to the department.
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Based on document review Licensee did not ensure to refund R1's responsible party after personal items were removed which poses a potential health, safety, or personal rights risk to the 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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5