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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602384
Report Date: 06/21/2022
Date Signed: 06/21/2022 08:11:11 PM

Unsubstantiated


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
03/22/2022 and conducted by Evaluator Don Senaha
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220322134810
FACILITY NAME:FOUNTAINVIEW AT GONDA WESTSIDEFACILITY NUMBER:
198602384
ADMINISTRATOR:OFRECIO, CHARLETTEFACILITY TYPE:
741
ADDRESS:12490 WEST FIELDING CIRCLETELEPHONE:
(424) 216-7788
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:286CENSUS: 232DATE:
06/21/2022
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:James Mackay - Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not quarantining resident.
Staff do not accord resident dignity in their relationship.
INVESTIGATION FINDINGS:
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On 06/21/2022, Licensing Program Analyst (LPA) Don Senaha conducted a subsequent unannounced complaint visit to this facility and met with Executive Director James Mackay. The purpose of this visit was to deliver the findings of the allegations listed above.

On 3/30/2022, LPA conducted the initial complaint visit with Executive Director James Mackay. On 04/19/2022 LPA conducted a subsequent unannounced complaint visit to this facility and met with Executive Director James Mackay and Health Services Director Clarissa Townes.

The investigations consisted of the following: LPA requested resident roster, staff roster and other service documents. LPA interviewed residents (R1-R11) and staff (S1-S6).
A plant inspection of the facility was conducted on 03/30/2022.

Investigation revealed:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
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 6
Control Number 11-AS-20220322134810
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: 06/21/2022
NARRATIVE
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Allegation: Staff are not quarantining resident.

During the course of the investigation, LPA was unable to find any witnesses or documentation supporting the allegation above.

Resident (R1) stated resident (R1) was not able to walk around the facility when resident (R1) was isolated. Resident (R2) stated resident (R1) was isolated in room when resident (R1) tested positive for covid-19. Resident (R2-R3, R5-R11) stated they have never been exposed or tested positive for covid-19.

The majority of the staff (4 of 6) stated residents do isolate and quarantine in their rooms when they test positive or are exposed to covid-19. Executive Director James Mackay stated no residents are allowed to walk around the facility when they are under isolation or quarantine. Executive Director James Mackay stated if exposed they are quarantined for 14 days following the guidelines of PIN 21-49-ASC.

Witness (W1) stated the facility did isolate family member resident (R4) when she tested positive for covid-19.

Based on LPA’s interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated

Allegation: Staff do not accord resident dignity in their relationship.

During the course of the investigation, LPA was unable to find any documents or witnesses supporting the allegation above. LPA reviewed and observed a copy of the member handbook (54 pages) including general policies and guidelines, communications – information services and member code of conduct among other topics given to each resident upon admission to the facility. LPA reviewed and observed copies of in-service training, with the latest training for abuse and infection prevention given to staff in March 2022.

The majority of the residents stated they have no issues or concerns about the facility, staff or its Management. The majority of the residents stated they have no issues moving around freely in the facility. The majority of the residents stated have no issues or concerns with suggestions that are made by the facility staff or Management.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20220322134810
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: 06/21/2022
NARRATIVE
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Staff (S1-S2, S5-S6) stated there are no issues or concerns with residents not following facility rules. Staff (S1-S6) stated they have no issues or concerns with suggestions made to residents by Management to help them keep them safe. Staff (S4) stated the facility does use emails and a journal newspaper to send out information to residents. Staff (S6) and Executive Director James MacKay stated the house rules for each resident is in the member handbooks.

Based on LPA’s interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
03/22/2022 and conducted by Evaluator Don Senaha
COMPLAINT CONTROL NUMBER: 11-AS-20220322134810

FACILITY NAME:FOUNTAINVIEW AT GONDA WESTSIDEFACILITY NUMBER:
198602384
ADMINISTRATOR:OFRECIO, CHARLETTEFACILITY TYPE:
741
ADDRESS:12490 WEST FIELDING CIRCLETELEPHONE:
(424) 216-7788
CITY:PLAYA VISTASTATE: CAZIP CODE:
90094
CAPACITY:286CENSUS: 232DATE:
06/21/2022
UNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:James Mackay - Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff force residents to stay in their room.
INVESTIGATION FINDINGS:
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13
On 06/21/2022, Licensing Program Analyst (LPA) Don Senaha conducted a subsequent unannounced complaint visit to this facility and met with Executive Director James Mackay. The purpose of this visit was to deliver the findings of the allegation listed above.

On 3/30/2022, LPA conducted the initial complaint visit with Executive Director James Mackay. On 04/19/2022 LPA conducted a subsequent unannounced complaint visit to this facility and met with Executive Director James Mackay and Health Services Director Clarissa Townes.

The investigations consisted of the following: LPA requested resident roster, staff roster and other service documents. LPA interviewed residents (R1-R11) and staff (S1-S6).

A plant inspection of the facility was conducted on 03/30/2022.
Investigation revealed:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20220322134810
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: 06/21/2022
NARRATIVE
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Allegation: Staff force residents to stay in their room.

During the course of the investigation, LPA was able to obtain documents and witnesses supporting the allegation listed above.

Resident (R2) stated she witnessed a chair wedged under the door of resident (R1) during resident (R1) isolation period. Executive Director James Mackay provided LPA Senaha a copy of the facility report including interviews, review of timecards and camera footage where staff (S7) used a chair as an “alarm system” in the sense that the resident would open his door which would bang the chair and alert the staff member that he was attempting to ambulate out of his room.

Executive Director James Mackay also sent CCLD an incident report reporting an incident where a staff member used a chair as an “alarm system” in the sense that the resident would open his door which would bang the chair and alert the staff member that he was attempting to ambulate out of his room. The chair was used Friday night, March 11th, 2022, into early Saturday morning, March 12th, 2022.

Based on LPA’s interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20220322134810
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: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidence by:
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The Licensee suspended the staff member immediately who later then resigned. LPA received training documents for staff on abuse which was given to staff immediately following incident on 3/21/22.
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Based on observation, interviews, and record reviews, resident (R2) was not accorded a safe environment when staff used a chair as an “alarm system” when a client would open the door. This violation poses a potential health and safety risk to residents 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don SenahaTELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6