361880853-8-24-2021-18-AS-KCLS-C69MLW-20210826094301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880853
Report Date: 08/24/2021
Date Signed: 08/24/2021 10:38:48 AM

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
09/21/2020 and conducted by Evaluator Christine Le

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200921162823

FACILITY NAME:	MOUNTAIN VIEW PLEASANT LIVING		FACILITY NUMBER:	361880853
ADMINISTRATOR:	BAUER, VIRGINIA		FACILITY TYPE:	740
ADDRESS:	2258 MENTONE BLVD		TELEPHONE:	(909) 810-1500
CITY:	MENTONE	STATE: CA	ZIP CODE:	92359
CAPACITY:	20	CENSUS: 13	DATE:	08/24/2021
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Virginia 'Ginnie' Bauer		TIME COMPLETED:	10:48 AM

ALLEGATION(S):

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Staff are not administering medications as prescribed
Staff are not qualified to administer medication
Neglect/lack of supervision resulting in resident developing sores

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to investigate the above allegations. LPA met with administrator Ginnie Bauer.

LPA conducted interviews and reviewed facility files. The first allegation indicates that Resident 1 (R1) and Resident 2 (R2) are being over-medicated with Medication 1 (M1). During the interviews and file review, LPA was informed that M1 was discontinued for R1. For R2, LPA was informed that there was a misunderstanding with staff members where it appeared R2 was not receiving M1 as prescribed, but upon further review, LPA observed that M1 was being administered correctly. LPA reviewed the residents' MARS log and observed that the medications are being administered as prescribed. The second allegation indicates that staff are not qualified to administer medications. LPA conducted a file review and observed that the staff received 24 hours of initial training which including hands-on shadowing training for administering medications. The third allegation indicates that due neglect/lack of supervision Resident 3 (R3) sustained sores. During the interviews and file review, LPA observed that R1 did not sustain sores,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine Le	TELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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-20200921162823

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: MOUNTAIN VIEW PLEASANT LIVING	FACILITY NUMBER: 361880853
	VISIT DATE: 08/24/2021

NARRATIVE

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pressures injuries, and/or blisters. LPA observed that R3 is bedridden and staff turn the resident every 2 hours. LPA observed that the facility documented when the staff turned the resident. During the interviews and file review, LPA was informed that R3 had a fungal infection on his/her back but hospice was notified and it was resolved with medication.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine Le	TELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC9099 (FAS) - (06/04)

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