366409921-7-20-2020-18-AS-KCLS-BRYVY6-20200729165036

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 07/16/2020
Date Signed: 07/20/2020 09:58:53 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
06/08/2020 and conducted by Evaluator Christine Le

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200608144138

FACILITY NAME:	MOUNTAIN VIEW RESIDENTIAL CARE		FACILITY NUMBER:	366409921
ADMINISTRATOR:	ILAGAN, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	9073 OLIVE ST		TELEPHONE:	(909) 822-5174
CITY:	FONTANA	STATE: CA	ZIP CODE:	92335
CAPACITY:	24	CENSUS: 22	DATE:	07/16/2020
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Channe Carlos		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Lack of supervision resulting in resident giving medication to another resident

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Christine Le contacted the facility via telephone to conclude a complaint investigation via telephone due to COVID-19. LPA identified herself and discussed the purpose of the call and the elements of the allegation with administrator Channe Carlos.

The investigation consisted of file review and interviews with relevant parties. The allegation indicates that due to a lack of supervision Resident 1 (R1) was giving Resident 2 (R2) his/her nighttime dose of Medication 1 (M1). M1 is used to treat certain mental/mood conditions. LPA spoke with the staff and residents involved. R1 and R2 were roommates at the time when this occurred. An interview with the staff revealed that staff assist the residents with taking their medications. The staff will walk throughout the facility, dispense the medications to the residents, and watch them take it individually. Interviews with both residents and staff confirmed that the staff are supervising them while dispensing medications. An interview with R1 revealed that although the staff were supervising the residents - he/she uses discreet methods to hide the medication. R1 explained that he/she hid the medication to give to R2 as it helped him/her sleep.

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: 07/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020

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 2

Control Number 18-AS-20200608144138

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 RESIDENTIAL CARE	FACILITY NUMBER: 366409921
	VISIT DATE: 07/16/2020

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R2 confirmed this information. LPA was informed that once the staff were notified of this practice, a meeting was held between the administrator, R1, and R2. At the meeting, it was decided that R1 and R2 were no longer going to be roommates. Since the incident, staff have taken extra precaution to ensure the residents were receiving their medications as prescribed. LPA was informed by the staff and residents that this inappropriate practice stopped once the residents were separated. Interviews also revealed in general that there were no adverse effects as a result of the medication changes for the residents involved. During the file review, LPA observed that on 5/10/20 R1 had an asthma attack and was hospitalized but was informed that R1 has a documented history of asthma problems.

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 with the administrator via telephone and a copy of this report was provided to the administrator via email. Report with facility signature was obtained.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine Le	TELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2