198602384-8-6-2021-11-AS-MCAA-C6PUYK-20210909160004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602384
Report Date: 08/06/2021
Date Signed: 08/06/2021 02:06:24 PM

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 DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2021 and conducted by Evaluator Jennifer Jones

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210728170220

FACILITY NAME:	FOUNTAINVIEW AT GONDA WESTSIDE		FACILITY NUMBER:	198602384
ADMINISTRATOR:	OFRECIO, CHARLETTE		FACILITY TYPE:	741
ADDRESS:	12490 WEST FIELDING CIRCLE		TELEPHONE:	(424) 216-7788
CITY:	PLAYA VISTA	STATE: CA	ZIP CODE:	90094
CAPACITY:	286	CENSUS: 240	DATE:	08/06/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Emily Perkins, Operations Associate		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility does not have a complete emergency disaster plan.
Staff are not properly trained.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Jennifer Jones initiated a complaint visit to Fountainview at Gonda regarding the allegations listed above. Upon arrival LPA was greeted by Executive Director, James Mackay and Operation Associate, Emily Perkins. LPA explained the reason for the visit.

On 08/06/21, LPA Jones conducted a virtual technical assistance visit with Department of Public Health Nurse, Juliana Aguayo, Executive Director, James Mackay and Operations Associate, Emily Perkins. During the visit, LPA observed the facility preventative covid measures in place and requested copies of the facility emergency disaster plan and staff training.

The allegation revealed the following: For allegation: (Facility does not have a complete emergency disaster plan.) Operations Associate, Emily Perkins sent LPA the facility Disaster and Emergency plan dated 2013. The plan does not indicate the updates from PIN 19-09 ASC that was released April 8, 2019 for an updated Disaster and Emergency Plan form for Residential Care Facilities for the Elderly (RCFEs). The plan also

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

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 3

Control Number 11-AS-20210728170220

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FOUNTAINVIEW AT GONDA WESTSIDE	FACILITY NUMBER: 198602384
	VISIT DATE: 08/06/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

does not address the equipment needed to transport residents in the event of evacuation.

For allegation: (staff are not properly trained.) Operations Associate, Emily Perkins sent LPA a staff signature list of staff who reviewed and approved the Disaster and Emergency manual for Fountainview at Gonda. This list of signatures is acknowledge of the Disaster and Emergency Plan dated 2013. LPA does not observe an updated training for the staff that reflects PIN 19-09 ASC that was released April 8, 2019.

Based on LPAs observations and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.

A copy of the report was given to Operations Associate, Emily Perkins

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20210728170220

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 DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FOUNTAINVIEW AT GONDA WESTSIDE	FACILITY NUMBER: 198602384
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/13/2021 Section Cited CCR 87212(a)(D)	1 2 3 4 5 6 7	Emergency Disaster Plan Each facility shall have a disaster and mass casualty plan of action. Transportation arrangements. This requirement is not met as evidence by: Based on LPA record review, the facility does not have an updated Disaster and Emergency manual that reflects PIN 19-09 ASC that was released April 8, 2019.	1 2 3 4 5 6 7	The administrator will submit an updated plan that reflects the updates in PIN 19-09 ASC and will indicate the equipment needed to transport residents. After completed, the administrator will conduct a staff training with the new updates and submit to LPA by POC due date.
	8 9 10 11 12 13 14	The plan also does not address the equipment needed to transport residents in the event of evacuation.	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.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3