236803448-5-5-2022-21-AS-BMOS-CF7NXN-20220608105125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 236803448
Report Date: 05/05/2022
Date Signed: 05/05/2022 06:07:33 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
03/22/2022 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-NP-20220322080309

FACILITY NAME:	MOUNTAIN VIEW ASSISTED LIVING		FACILITY NUMBER:	236803448
ADMINISTRATOR:	SMITH, ANGIE		FACILITY TYPE:	740
ADDRESS:	1343 S DORA ST		TELEPHONE:	(707) 462-6212
CITY:	UKIAH	STATE:	ZIP CODE:	95482
CAPACITY:	64	CENSUS: 37	DATE:	05/05/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Angie Smith		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Personal Rights
Lack of Supervision
Facility in Disrepair
Lack of Personal Accommodations and Services
Facility not reporting incidents

INVESTIGATION FINDINGS:

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At approximately 12:15PM, 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 personal rights of residents were violated on several occasions. Continent residents were placed in adult padded undergarments in lue of prompting residents to use restroom. Based on interviews conducted, resident was found asleep on a toilet by a visitor who informed staff, resident was in the same position approximately 45 minutes later, when visitor was leaving. Based on LPA observations, the dining chairs and tables in memory care are worn to the point that cleaning and disinfection is not possible. The laundry room floor in memory care is crumbling and mold is present. LPA observed during visit on 03/22/2022, shared restrooms did not contain paper towels... Continued on LIC9099-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: 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 5

Control Number 21-NP-20220322080309

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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To allow proper hand sanitation and meet infection control requirements. Paper towels were placed in the dispensers during the visit. Based on record review and interviews conducted, facility did not report several falls resulting in visits to the emergency department to either the family or CCLD.

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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
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: 2 of 5

Control Number 21-NP-20220322080309

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 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities:(3) To be free from punishment...or interfering with daily living functions such as...or elimination. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to conduct training with all care staff on personal rights for residents in care. Training to be scheduled by POC date of 05/06/2022. Completed training sign in sheet and course material to be
	8 9 10 11 12 13 14	Based on records reviewed and interviews conducted, staff placed adult diapers on a resident that was continent and failed to assist residents in a timely manner with toileting needs. This poses an immediate personal rights risk for residents.	8 9 10 11 12 13 14	submitted to CCL by POC date of 05/31/2022.
Type B 05/31/2022 Section Cited HSC 1569.312(e)	1 2 3 4 5 6 7	1569.312 Basic services requirements:(e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as	1 2 3 4 5 6 7	Licensee to ensure facility staff are in sufficient numbers to ensure supervision of residents in the facility. Licensee to submit updated LIC500 to show care giving staffing levels in both AL and memory care
	8 9 10 11 12 13 14	evidenced by: Based on interviews conducted, Licensee did not ensure resident was observed, resulting in resident being left on a toilet for an extended period of time. This poses a potential health or safety risk to residents	8 9 10 11 12 13 14	that will meet 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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
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: 3 of 5

Control Number 21-NP-20220322080309

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 B 05/31/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation:(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on observations, Memory care dining	1 2 3 4 5 6 7	Licensee to ensure facility is maintained is a clean and safe manner. Facility has ordered replacement furniture. POC cleared.
	8 9 10 11 12 13 14	furniture was worn to the point that sanitation is not possible. This poses a potential health, safety or personal rights risk to residents.	8 9 10 11 12 13 14
Type B 05/05/2022 Section Cited CCR 87307	1 2 3 4 5 6 7	87307 Personal Accommodations and Services:(D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Based on observation, Licensee did not	1 2 3 4 5 6 7	Licensee to ensure shared hand washing stations are equipped with disposable towels or air dryers. Towels were replenished during visit. POC cleared at time of visit.
	8 9 10 11 12 13 14	ensure disposable towels were in place in shared resident restrooms. This poses a potential health risk to residents.	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: 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 5

Control Number 21-NP-20220322080309

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 B 05/31/2022 Section Cited CCR 87211	1 2 3 4 5 6 7	87211 Reporting Requirements:(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on records reviewed, Licensee did not	1 2 3 4 5 6 7	Licensee to ensure incidents are reported to responsible parties and CCLD within regulation. Staff responsible for reporting, to receive training on reporting requirements.
	8 9 10 11 12 13 14	report several resident falls resulting in injury. This poses a potential health, safety or personal rights risk to residents.	8 9 10 11 12 13 14	Completed training sign in sheet to be submitted to CCL by POC date of 05/31/2022.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 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)

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