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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 236803448
Report Date: 12/10/2021
Date Signed: 12/10/2021 01:45:11 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2021 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211117140325
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:
12/10/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Frances KingTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are falsifying logs.

Facility does not provide adequate activities.

Facility is not following resident care plans.
INVESTIGATION FINDINGS:
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Business office manager Frances King, reviewed records and interviewed staff. Based on records reviewed and interviews conducted, facility staff did not document certain activities as they occured. LPA reviewed a care plan for a resident, R3, that stated 30 minute checks were to be conducted. The log for this activity was filled out completely for the AM shift, (6AM-2PM), at 10:31AM. LPA reviewed another resident file, R2, and interviewed staff. LPA observed a wound care appointment not being kept on 11/30/2021, due to lack of staff to transport resident. LPA reviewed activity calendars, resident council minutes and interviewed residents. Based on interviews conducted, the activities program is not reliable to provide the activity when scheduled. LPA was informed that the residents are often left to watch a video, with no staff interaction. Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2021 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20211117140325

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:
12/10/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Frances KingTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Residents are having multiple falls while in care.
Residents are sustaining unexplained injuries while in care.
Staff are dropping residents during transfers.
Staff are not calling 911 timely after resident falls.
Staff are not administering medications as prescribed.
Facility is not screening visitors for COVID-19 prior to entry.
Unsanitary practices in the facility kitchen.
INVESTIGATION FINDINGS:
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Business office manager Frances King, reviewed records and interviewed staff. LPA observed facility staff are assisting residents while ambulating or transferring as needed. Falls occur at times and staff respond in a timely manner. Information is entered into the resident record and notifications are made to the physician to possibly address the reasons for the fall. As staff observe residents, they pass information onto the following shift and enter observations into resident records regarding injuries that are observed. There are no 1:1 staff/resident observations at this time. Based on interviews conducted, staff are not "dropping" residents during transfers. Staff assist residents transferring from wheelchair to bed and sometimes, during the transfer, the legs of the resident give out, causing staff to assist resident to the ground. Continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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 6
Control Number 21-AS-20211117140325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: MOUNTAIN VIEW ASSISTED LIVING
FACILITY NUMBER: 236803448
VISIT DATE: 12/10/2021
NARRATIVE
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Continued from LIC9099A...
LPA interviewed staff and residents and none admitted they dropped or were dropped while being assisted. LPA reviewed resident call logs from the pendant alarm system used at the facility. LPA reviewed logs from September through November 2021. Calls for assistance ranged, on average, from 10 seconds to 8 minutes. LPA reviewed incident reports regarding incidents that occurred in the facility where emergency personnel were contacted. The time duration from staff arriving to the resident to assess the situation and then contacting emergency personnel was reasonable, in the records reviewed. LPA reviewed resident records and interviewed staff regarding the administration of medication. With the exception of previously addressed medication errors, medications are administered as ordered by physician. Facility conducted retraining for medication technicians as a plan of correction for a previous incident. LPA observed 2 electronic tablets at the entrance of the facility where staff and visitors complete a COVID-19 health screening. There are signs alerting incoming people to complete the survey upon entry and staff have all been trained to complete the screening before their shift. The system will alert several positions in management if a person fails the screening. LPA toured the kitchen and food storage areas. LPA observed the staff working in the kitchen were wearing the appropriate PPE and the counters and food prep areas were clean. Food storage areas were clean and orderly and food was stored properly to prevent contamination or spoilage.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2021 and conducted by Evaluator Christopher Arnhold
COMPLAINT CONTROL NUMBER: 21-AS-20211117140325

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:
12/10/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Frances KingTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Meals are not being served timely.

Buildings and grounds not safe
INVESTIGATION FINDINGS:
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with Business Office Manager Frances King, reviewed records and interviewed staff. Based on LPA observation and interviews conducted, facility meals are served at the posted hours. Residents sometimes arrive to the dinning room early and staff provide beverages and sides until the main meal is served. LPA toured the building and grounds and interviewed the acting Fire Marshal regarding the facility. Lighting in the building provides enough light and bedrooms have the required equipment, which is in good condition. The surrounding vegitation is within the standards of the fire code, and is not a danger to the facility.
This agency has investigated the above allegations. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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 21-AS-20211117140325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: MOUNTAIN VIEW ASSISTED LIVING
FACILITY NUMBER: 236803448
VISIT DATE: 12/10/2021
NARRATIVE
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Continuation from 9099...
Based on interviews conducted, residents told LPA their input is either not asked for or not listened to regarding what activities are offered at the facility. Based on interviews conducted, activities in the memory care section are not provided regularly.

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 Frances King and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20211117140325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MOUNTAIN VIEW ASSISTED LIVING
FACILITY NUMBER: 236803448
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/13/2021
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care:The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirment is not
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Licensee to ensure medical services are provided as ordered. Licensee will develop a written plan to track medical and dental appointments to ensure residents make the appointment.
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as evidence by: Based on interviews conducted, Licensee did not ensure R1 received appropriate medical care as ordered, for a wound. This poses an immediate health risk to residents in care.
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Written Plan to be submitted to CCL by POC date of 12/13/2021.
Type B
12/31/2021
Section Cited
CCR
87219
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87219 Planned Activities:Residents served shall be encouraged to contribute to the planning, preparation, conduct, clean-up and critique of the planned activities. This requirement is not met as
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Licensee to ensure residents are encouraged to contribute to the activities in the facility. Licensee to also ensure sufficient staff are available to conduct the activities. Licensee to submit written plan to
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evidenced by: Based on interviews conducted, Licensee did not ensure residents feedback of activities was encouraged. This poses a potential personal rights risk to residents in care.
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address planned activity program with residents to receive input. Plan to be submitted to CCL by POC date of 12/31/2021.
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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6