<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005580
Report Date: 11/13/2020
Date Signed: 11/16/2020 08:42:09 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2020 and conducted by Evaluator Melana Llopis
COMPLAINT CONTROL NUMBER: 27-AS-20200311144856
FACILITY NAME:MOUNTAIN MANOR SENIOR RESIDENCEFACILITY NUMBER:
347005580
ADMINISTRATOR:JAMES JORDANFACILITY TYPE:
740
ADDRESS:6101 FAIR OAKS BLVDTELEPHONE:
(415) 250-2721
CITY:FAIR OAKSSTATE: CAZIP CODE:
95608
CAPACITY:33CENSUS: 16DATE:
11/13/2020
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator, Darrell PriceTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has inadequate record keeping for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Llopis contacted the facility via telephone on 11/13/2020 due to COVID-19 precautionary measures. LPA spoke with Administrator, Darrell price and explained the purpose of the call was to deliver findings for a complaint the Department received on 03/11/2020.

Throughout the course of the investigation the Department conducted multiple interviews and reviewed documentation pertinent to the allegation: Facility has inadequate record keeping for resident. Documentation reviewed and interviews revealed on 01/27/2020, a mix up occurred between R1 and R2 regarding a hair care service. The Beauty Log shows R2’s name with R1’s room number. Transaction statements reviewed show the facility mischarged R1 for a hair care service billed on 02/29/2020, and was later credited back that same day. Then on 03/01/2020, key witness found unopened mail addressed to R2 in R1’s room. The mail found in R1’s room included R2's credit card statements. R2 confirmed they do not always receive their mail from the facility.

Due to the above information, the Department finds the allegation: Facility has inadequate record keeping for resident to be SUBSTANTIATED, A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D, per Title 22 Regulations, Division 6.
Exit interview conducted, appeal rights provided, and copy of report left at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2020 and conducted by Evaluator Melana Llopis
COMPLAINT CONTROL NUMBER: 27-AS-20200311144856

FACILITY NAME:MOUNTAIN MANOR SENIOR RESIDENCEFACILITY NUMBER:
347005580
ADMINISTRATOR:JAMES JORDANFACILITY TYPE:
740
ADDRESS:6101 FAIR OAKS BLVDTELEPHONE:
(415) 250-2721
CITY:FAIR OAKSSTATE: CAZIP CODE:
95608
CAPACITY:33CENSUS: 16DATE:
11/13/2020
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator, Darrell PriceTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility inappropriately administered incorrect medication for resident.
Facility failed to safeguard resident’s personal belongings.
Facility did not follow admission agreement.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Llopis contacted the facility via telephone due to COVID-19 precautionary measures on 11/13/2020. LPA spoke with Administrator, Darrell Price and explained the purpose of the visit was to deliver findings for a complaint the Department received on 03/11/2020.

Throughout the course of the investigation the Department conducted multiple interviews and reviewed documentation pertinent to the investigation.


***Continuation on 9099-C***
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
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 7
Control Number 27-AS-20200311144856
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MOUNTAIN MANOR SENIOR RESIDENCE
FACILITY NUMBER: 347005580
VISIT DATE: 11/13/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility inappropriately administered incorrect medication for resident.

On 02/29/2020 R1 was admitted to Mercy San Juan hospital. Upon admission, the facility provided R1’s medication list. According to key witness, the medication list may or may not have been R1’s. Hospital records reviewed indicate the chief complaint was abdominal pain and diarrhea. According to the hospital’s pharmacist, the hospital did not need to request a corrected medication list from the facility for R1. Hospital documentation reviewed indicates the medication list provided by the facility for R1 was accurate and not of concern. The Department compared R1’s Physician’s medication list to Centrally Stored Medication Records and found no errors. The allegation is found to be UNFOUNDED.

Allegation: Facility failed to safeguard resident’s personal belongings.

Based on interviews conducted and documentation reviewed, R1 moved into the facility on 12/08/2017. Upon admission, R1 declined to have cash and/or other valuables entrusted to the facility to safeguard. Interviews with a random sample of four (4) residents stated they have not had any personal items go missing without the facility replacing. The allegation is found to be UNFOUNDED.


Allegation: Facility did not follow admission agreement.

CCL conducted interviews with staff, family members of residents, and the Director of the Assisted Living Waiver Program. Interviews indicate R1 was a part of the Assisted Living Waiver Program, designed to set the exact living amount the resident pays. According to ALWP, the resident’s living rate is determined by their income which can increase annually. The facility was notified by ALWP that the resident’s SSI income had increased, therefore their monthly fees reflected the increase. The facility provided the letter sent to family members notifying them of the change on January 23, 2020, the day the ALWP first notified the facility. The Director of ALWP stated it is not policy but a courtesy for the ALWP to notify families of changes as soon as they are made aware of potential income increases of their partners. Due to the late notice, the facility agreed to postpone all increases until February 2020. The allegation is found to be UNFOUNDED.

Based on interviews and records reviewed, the allegations listed are found to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. Copy of report and appeal rights provided. Facility will sign and send a signed copy to CCL.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20200311144856
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MOUNTAIN MANOR SENIOR RESIDENCE
FACILITY NUMBER: 347005580
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2020
Section Cited
CCR
87468.1(a)(15)
1
2
3
4
5
6
7
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(15)To send and receive unopened correspondence in a prompt manner.
This requirement was not met as evidenced by: interviews and document review. The Licensee did not provide residents in care with
1
2
3
4
5
6
7
Licensee agrees to improve their record keeping to ensure residents receive their correct mail and are billed for correct services received. Licensee will ensure their record keeping system addresses residents who share the same first and last name. A plan for improving record keeping that ensures residents receive their correct mail
8
9
10
11
12
13
14
their correct mail. This poses a potential risk to residents in care.
8
9
10
11
12
13
14
and are billed for correct services is due to CCL by POC date.
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: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2020 and conducted by Evaluator Melana Llopis
COMPLAINT CONTROL NUMBER: 27-AS-20200311144856

FACILITY NAME:MOUNTAIN MANOR SENIOR RESIDENCEFACILITY NUMBER:
347005580
ADMINISTRATOR:JAMES JORDANFACILITY TYPE:
740
ADDRESS:6101 FAIR OAKS BLVDTELEPHONE:
(415) 250-2721
CITY:FAIR OAKSSTATE: CAZIP CODE:
95608
CAPACITY:33CENSUS: 16DATE:
11/13/2020
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator, Darrell PriceTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was over charged for service not authorized.
Facility telephone is not being answered regularly.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Llopis contacted the facility via telephone due to COVID-19 precautionary measures on 11/13/2020. LPA spoke with Administrator, Darrellnd Price and explained the purpose of the visit was to deliver findings for a complaint the Department received on 03/11/2020.

Throughout the course of the investigation the Department conducted multiple interviews and reviewed documentation pertinent to the investigation.

Allegation: Resident was over charged for service not authorized.
Complaint alleged R1 was billed for a hair care service not authorized.
On 02/29/2020, R1 was billed for an $18.00 hair care service and credited the charge the same day. Interviews with staff stated R1 normally does not receive hair care services but is encouraged for hygiene purposes. Interviews with R1's family member stated R1 has "never received hair care before and has never allowed anyone to touch or care for their hair." Interviews with Salon Representative (SR) stated they could not verify if they did or did not cut R1's hair. SR reviewed a picture of R1 and still could not verify. R1 was unable to be interviewed.

***See continuation on 9099-C***

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20200311144856
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: MOUNTAIN MANOR SENIOR RESIDENCE
FACILITY NUMBER: 347005580
VISIT DATE: 11/13/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility telephone is not being answered regularly.

Interviews with five (5) staff and four (4) residents stated the facility has an efficient telephone system. Residents stated they have not had any issues receiving or making calls using the facility telephone system. Staff stated they check their voicemail throughout their shifts and reply to missed calls daily. LPA Llopis contacted the facility multiple times during the investigation process and had success in reaching a staff member. One key witness stated they have called the facility multiple times without receiving a call back.

Due to the above information, the Department finds the allegations, Resident was over charged for service not authorized, Facility telephone is not being answered regularly to be UNSUBSTANTIATED, a finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

There are no deficiencies per Title 22 Regulations, Division 6, Chapter 8 being cited.

Exit interview conducted, copy of report and appeal rights provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 7