236803448-6-20-2023-21-AS-HDBI-CTG7YH-20230705220446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 236803448
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:53:10 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2023 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20230410152505

FACILITY NAME:	MOUNTAIN VIEW ASSISTED LIVING		FACILITY NUMBER:	236803448
ADMINISTRATOR:	JEANETTE KINNEY		FACILITY TYPE:	740
ADDRESS:	1343 S DORA ST		TELEPHONE:	(707) 462-6212
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY:	64	CENSUS:	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Alexandria Rodriguez		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff do not respond to residents call buttons in timely manner
Facility lacks adequate staffing to meet resident's needs

INVESTIGATION FINDINGS:

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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conclude an investigation into the above allegations. LPA met with Executive Director Alexandria Rodriguez and interviewed individuals. During the course of this investigation, LPA reviewed call log records for the months of January thru April. LPA observed there were approximately ten residents that showed several calls that had a response time of longer than 20 minutes. Many of these calls were during a meal time in which care giving staff were re-tasked with serving residents meals. LPA reviewed staff schedules and found staffing levels in memory care did not meet the needs of residents that required 2 staff to assist. LPA reviewed schedules from mid April to present and observed staffing levels have increased in memory care.
Continued on LIC 9099-C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

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 21-AS-20230410152505

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MOUNTAIN VIEW ASSISTED LIVING	FACILITY NUMBER: 236803448
	VISIT DATE: 06/20/2023

NARRATIVE

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Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Alexandria Rodriguez and Appeal rights were given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230410152505

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MOUNTAIN VIEW ASSISTED LIVING	FACILITY NUMBER: 236803448
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/21/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General:(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met	1 2 3 4 5 6 7	Facility has added staffing positions in the memory care section and has posted advertisements for additional staff. POC cleared at time of visit.
	8 9 10 11 12 13 14	as evidenced by: Based on records reviewed, Licensee did not ensure sufficient staffing to meet resident needs. This poses an Immediate Health, Safety or Personal Rights risk to residents in care.	8 9 10 11 12 13 14
Type B 06/30/2023 Section Cited CCR 87208(a)	1 2 3 4 5 6 7	87208 Plan of Operation:(a)Each facility shall have and maintain a current, written definitive plan of operation. This requirement is not met as evidenced by: Based on records reviewed, Resident	1 2 3 4 5 6 7	Facility has implemented a plan to review call logs after each shift and conduct an investigation immediately to determine the cause of any call delay of more than ten minutes. POC cleared at time of visit.
	8 9 10 11 12 13 14	Handbook states the pendants are for use in an emergency. Response times for 171 calls were longer than 20 minutes. This poses a potential Health, Safety or Personal Rights risk to residents in care.	8 9 10 11 12 13 14

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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