198602384-9-16-2021-11-AS-MCAA-C74QYR-20210922123532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602384
Report Date: 09/16/2021
Date Signed: 09/16/2021 01:27:39 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
09/10/2021 and conducted by Evaluator Jennifer Jones

COMPLAINT CONTROL NUMBER: 11-AS-20210910162052

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: 237	DATE:	09/16/2021
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	James Mackay, Executive Director		TIME COMPLETED:	01:43 PM

ALLEGATION(S):

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Staff did not respond to resident's call for assistance

INVESTIGATION FINDINGS:

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

On 09/16/21, LPA Jones toured the facility and interviewed Executive Director James Mackay, Operations Associate, Emily Perkins (via telephone) and 10 residents who reside in the community about the allegation. During the visit, LPA requested copies of the resident and staff roster including staff schedule and a schedule of the nurses who worked on 09/09/21 and 09/10/21. LPA also requested a list of residents who were sent to the hospital by ambulance on 09/09/21 and 0910/21.

The allegation revealed for the following: For allegation (Staff did not respond to resident's call for assistance.) It is being alleged that a resident called for a nurse to obtain help however, there was no nurse on duty at the facility to assist the resident, which resulted in the resident having to call 911. Executive Director

Unsubstantiated

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: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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 11-AS-20210910162052

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: 09/16/2021

NARRATIVE

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James Mackay and Operations Associate, Emily Perkins both revealed during their interview that they do not recall the incident. ED James Mackay told LPA during the interview that the community was staffed with nurses on 09/09/21 and 09/10/21 and also provided LPA a copy of the staff schedule. LPA interviewed residents 1-10 about the allegation. Resident 1 revealed during her interview that she went to the hospital by ambulance on 09/09/21. R1 said she contacted her doctor's office first by phone and was told to call 911. R1 said she also contacted the community after calling 911 and nurse came right away to assist until the ambulance arrived. R1 also stated that the community contacted her while she was at the hospital to check on her. Residents 2-10 revealed during their interviews that they are all independent and do not require assistance with anything. Residents 2-10 stated that they have not experience a situation of staff not assisting them when they needed help nor do they know anyone in the community who called for help and staff didn't come. Some of the residents stated because of confidentiality, they do not know who goes to the hospital when they see an ambulance.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted and a copy of the report was given to Executive Director, James Mackay

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC9099 (FAS) - (06/04)

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