361880835-7-27-2023-18-AS-KCLS-CUXRMC-20230822130833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880835
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:49:48 PM

Unsubstantiated

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
11/24/2020 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 18-AS-20201124103332

FACILITY NAME:	VISTA BLUE MOUNTAIN		FACILITY NUMBER:	361880835
ADMINISTRATOR:	JACQUELINE PENN		FACILITY TYPE:	740
ADDRESS:	22325 BARTON ROAD		TELEPHONE:	(909) 420-0153
CITY:	GRAND TERRACE	STATE: CA	ZIP CODE:	92313
CAPACITY:	0	CENSUS: 0	DATE:	07/27/2023
		UNANNOUNCED	TIME BEGAN:	02:39 PM
MET WITH:	Ashley Willet Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Resident was neglected by staff while in care
Staff failed to seek medical attention for resident in a timely manner
Staff failed to keep the resident's room clean
Facility is malodorous
Staff failed to provide adequate food service
Staff failed to administer resident's medication in a timely manner
Staff failed to protect resident's personal belongings

INVESTIGATION FINDINGS:

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On 07/27/2023 at 2:39 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.

Allegation #1- Resident was neglected by staff while in care – Department staff reviewed resident 1 (R1’s) facility file documents and the investigation revealed that facility staff provided care and supervision to all residents in care. Department staff was unable to interview R1, and other resident’s due facility closure they were unavailable.

Allegation #2-Staff failed to seek medical attention for resident in a timely manner- Facility file documents reviewed for R1 provided daily notes of each time the resident was observed every two hours by staff, the notes revealed each time the resident was seen by the doctor. The investigation revealed that staff did seek medical attention as needed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 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 18-AS-20201124103332

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
	VISIT DATE: 07/27/2023

NARRATIVE

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Allegation #3- Staff failed to keep the resident's room clean- The Department was unable to determine if R1’s room was cleaned back in 2020 when R1 lived in the facility. During this investigation LPA was unable to corroborate if the staff failed to keep R1’s room clean as the facility is now closed.

Allegation #4- Facility is malodorous- LPA was unable to corroborate that the facility is malodorous there are no witnesses.

Allegation #5- Staff failed to provide adequate food service- Department staff was unable to corroborate that the staff failed to provide R1 with adequate food service. There was no evidence or witnesses.

Staff failed to administer resident's medication in a timely manner- Documents were reviewed and based on this information R1 was provided with their medications as prescribed by a physician from November 2019 through November 2020.

Staff failed to protect resident's personal belongings: Department staff’s interview with outside party revealed that R1 did receive some of their personal belongings and some were left behind. There were no witnesses or evidence to corroborate.

Based on documentation reviewed and interviews conducted during the investigation, the above findings are Unsubstantiated. A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Ashley Willett and a copy of the report was provided with appeal rights at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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