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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880835
Report Date: 08/27/2021
Date Signed: 08/27/2021 01:14:40 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200519095126
FACILITY NAME:VISTA BLUE MOUNTAINFACILITY NUMBER:
361880835
ADMINISTRATOR:TRABUCCO, MEGANFACILITY TYPE:
740
ADDRESS:22325 BARTON ROADTELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:150CENSUS: 79DATE:
08/27/2021
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Mayra Perez Business Office DirectorTIME COMPLETED:
01:32 PM
ALLEGATION(S):
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Facility staff failed to provide assistance in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to deliver findings for the allegation listed above. LPA identified herself and discussed the purpose of the visit and the elements of the above allegation with Mayra Perez Business Office Director. The Department conducted investigation of allegation to include interviews and records review.

Allegation: Facility staff failed to provide assistance in a timely manner.
A review of the emergency alert system revealed that R1 called for assistance on May 18, 2020. The emergency alert system records revealed that the call had been announced a total of 6 times. Staff responded to R1 twenty-nine minutes after R1's initial call. Based on the length of time that it took staff to respond to R1's initial call, the allegation of Facility staff failed to provide assistance in a timely manner is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted and a copy of this report, 9099D, and appeal rights were provided to Mayra Perez Business Office Director.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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 4
Control Number 18-AS-20200519095126
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA BLUE MOUNTAIN
FACILITY NUMBER: 361880835
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
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 was not met as evidenced by: A review of the emergency alert system revealed that R1 called for assistance on May 18, 2020. The emergency alert system records revealed that staff responded to R1 twenty-nine minutes after R1's initial call. The facility failed at ensuring staff was competent to provide services to meet R1's needs.
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The licensee agrees to conduct an inservice on responding to resident's call buttons. Proof is to be submitted to the department by 5pm on the due date indicated.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200519095126

FACILITY NAME:VISTA BLUE MOUNTAINFACILITY NUMBER:
361880835
ADMINISTRATOR:TRABUCCO, MEGANFACILITY TYPE:
740
ADDRESS:22325 BARTON ROADTELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:150CENSUS: 79DATE:
08/27/2021
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Mayra Perez Business Office DirectorTIME COMPLETED:
01:32 PM
ALLEGATION(S):
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Staff failed to provide adequate supervision resulting in resident being injured.
Facility failed to give resident medication as prescribed.
Staff failed to transport residents to appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George arrived at the facility unannounced to deliver findings for the allegation(s) listed above. LPA identified herself and discussed the purpose of the visit and the elements of the above allegation with Mayra Perez Business Office Director. The Department conducted investigation of allegation to include interviews and records review.

Allegation: Staff failed to provide adequate supervision resulting in resident being injured.
Interviews with staff and resident R1 revealed that R1 sustained a fall on May 18, 2020 while R1 was in a private room at or around five o'clock in the morning. A review of the facility employment schedule revealed that on May 18, 2020 there were four staff on duty at the time of R1's fall. LPA could not corroborate that staff failed to provide adequate supervision. The allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20200519095126
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA BLUE MOUNTAIN
FACILITY NUMBER: 361880835
VISIT DATE: 08/27/2021
NARRATIVE
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Allegation: Facility failed to give medication as prescribed.

LPA conducted Interviews with staff and residents. R1 revealed that the facility has administered medications correctly and has never missed being given their medications. LPA reviewed all medication prescribed to R1's as well as the Medical Authorization Record (MAR), which revealed that the facility administered R1's medications per physician’s orders. Therefore the allegation of facility failed to give medication as prescribed is UNSUBSTANTIATED.


Allegation: Staff failed to transport residents to appointments.

Feedback provided from Interviews with staff revealed that the facility requires for residents who require transportation to external appointments must complete a form notifying the facility of the desired date and time transportation is needed. Once the form is completed, the facility will provide transportation to the resident. Interviews with residents revealed that the facility provides a bus that transports residents to appointments outside of the facility. A review of facility records from April 2020 through May 2020 revealed that residents who signed up for transportation received transportation to appointments outside of the facility. R1 revealed during the interview that they do not rely on facility transportation and utilize Uber or a relative to transport them to their appointments. Based on interviews, and record review, the allegation of Staff failed to transport residents to appointments is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted and a copy of this report was provided to the Mayra Perez Business Office Director.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4