361880853-6-23-2022-56-AS-KCLS-CKTS9T-20221103134115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880853
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:56:03 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
06/17/2022 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20220617124956

FACILITY NAME:	MOUNTAIN VIEW PLEASANT LIVING		FACILITY NUMBER:	361880853
ADMINISTRATOR:	KHALID, AMBREEN		FACILITY TYPE:	740
ADDRESS:	2258 MENTONE BLVD		TELEPHONE:	(909) 810-1500
CITY:	MENTONE	STATE: CA	ZIP CODE:	92359
CAPACITY:	20	CENSUS: 18	DATE:	06/23/2022
		UNANNOUNCED	TIME BEGAN:	12:29 PM
MET WITH:	Director- Niaz Khalid		TIME COMPLETED:	04:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not properly appraise resident
Resident’s medical documents were falsified.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Bernadette Allen conducted an unannounced visit to the facility to commence a complaint investigation. LPA Allen was granted entrance by acting administrato Kara Richardson. At 12:45 PM the director Niaz Khalid arrived LPA Allen identified herself and discussed the elements of the visit regarding the above allegations.

The allegation #1 states that the facility did not properly appraise residents and allegation #2 medical documents were falsified. LPA interviewed (3) staff members (3) residents and reviewed (6) six residents files all of which were confirmed that files are in compliance. LPA identified physicians’ orders and records which were also in compliance.LPA was unable to corroborate the above allegations.LPA has determined that the allegations above are Unsubstantiated.

A finding that the complaints 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.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed with and a copy was provided to the Director Niaz Khalid.

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: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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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