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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 236803448
Report Date: 05/05/2022
Date Signed: 05/05/2022 06:05:47 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
04/15/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20220415132528
FACILITY NAME:MOUNTAIN VIEW ASSISTED LIVINGFACILITY NUMBER:
236803448
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:64CENSUS: 37DATE:
05/05/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Angie SmithTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Inadequate staffing to meet resident's needs.
Resident sustained a UTI while in care.
Resident's toileting needs are not being met.
Resident was left in soiled clothing for an extended period of time.
Resident's call button is not answered in a timely manner.
Resident's showering needs are not being met.
INVESTIGATION FINDINGS:
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to deliver investigative findings for the above allegations. LPA met with Executive Director Angie Smith. During the course of this investigation, LPA reviewed resident records, staffing schedules and conducted interviews with staff, residents and families. Based on these activities, LPA observed the facility did not have adequate staff to meet the needs of residents on several occasions. Care giving staff were assigned duties in the dining room in addition to their care giving duties, which led to residents needs not being met in a timely manner. Interviews and records reviewed showed that residents were not assisted timely causing some to sustain urinary track infections, not being assisted with bathing or toileting as needed and being left in soiled clothing for extended periods of time. A review of call button logs showed most calls were answered within...Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
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 4
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
04/15/2022 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20220415132528

FACILITY NAME:MOUNTAIN VIEW ASSISTED LIVINGFACILITY NUMBER:
236803448
ADMINISTRATOR:SMITH, ANGIEFACILITY TYPE:
740
ADDRESS:1343 S DORA STTELEPHONE:
(707) 462-6212
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY:64CENSUS: DATE:
05/05/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Angie SmithTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
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At approximately 10:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to deliver investigative findings for the above allegations. LPA met with Executive Director Angie Smith. During the course of this investigation, LPA reviewed resident records, staffing schedules and conducted interviews with staff, residents and families. Based on these activities, LPA was not able to verify that facility staff mismanaged residents medication.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20220415132528
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: 05/05/2022
NARRATIVE
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5 to 10 minutes, but further interviews revealed the call button was answered but care was not provided. Staff reset the call button and informed resident they would return when free but would not return.

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 Angie Smith and Appeal rights were given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20220415132528
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: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2022
Section Cited
CCR
87411(a)
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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
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Licensee to ensure facility has sufficient staff to meet the needs of residents in care. Licensee to submit updated LIC500 to show care giving staffing levels and dietary support personnel that will meet
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is not met as evidenced by: Based on records reviewed, interviews conducted, Licensee did not ensure sufficient staff were present to meet resident needs. This poses an immediate Health and Safety risk to residents.
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the needs of residents. LIC500 to be submitted to CCL every 30 days beginning 05/06/2022, and to be continued through 2022.
Type A
05/06/2022
Section Cited
CCR
87468.2
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (4) To care, supervision, and services that meet their individual needs...This requirement was not met as
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Licensee to ensure facility has sufficient staff to meet the needs of residents in care. Licensee to submit updated LIC500 to show care giving staffing levels and dietary support personnel that will meet
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evidence by: Based on interviews conducted and records reviewed, facility did not provide assistance with showering, toileting and daily care. This poses an immediate health, safety and personal rights risk to residents.
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the needs of residents. LIC500 to be submitted to CCL every 30 days beginning 05/06/2022, and to be continued through 2022.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4