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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880835
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:32:34 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2023 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20230503092034
FACILITY NAME:VISTA BLUE MOUNTAINFACILITY NUMBER:
361880835
ADMINISTRATOR:ASHLEY WILLETTFACILITY TYPE:
740
ADDRESS:22325 BARTON ROADTELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:0CENSUS: 0DATE:
07/27/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ashley Willett-AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not meet resident's showering needs
INVESTIGATION FINDINGS:
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On 07/27/2023 at 2:00 PM, Licensing Program Analyst (LPA) Bernadette Allen met with Administrator Ashley Willett at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings for the mentioned allegations.

Staff did not meet resident's showering needs
LPA Allen conducted interviews with R1’s responsible party and 1 outside party that said the resident’s activity of daily showers were not met. The records reviewed and interviews conducted revealed that R1 was reimbursed by waiving monthly fees for (2) two months because R1’s shower needs were not met.

Based on the interviews with the administrator, witnesses and documents reviewed the allegation 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. A deficiency is being cited on the attached LIC 9099-D
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 56-AS-20230503092034
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
, CA 92507

FACILITY NAME: VISTA BLUE MOUNTAIN
FACILITY NUMBER: 361880835
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2023
Section Cited
CCR
87459
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Functional Capabilities (a) 1-7
The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to:
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POC – Facility is currently Closed
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This regulation was not met as evidenced by: Based on interviews the facility staff did not ensure that the residents ADL’s were met by facility staff. This poses a potential health and safety risk to resident in care.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2