366409921-3-14-2023-56-AS-EMAN-CRAUU6-20230427155300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 03/14/2023
Date Signed: 03/14/2023 11:42:20 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
03/08/2023 and conducted by Evaluator Paola Guerrero

COMPLAINT CONTROL NUMBER: 56-AS-20230308142036

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: 24	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Channe Carlos		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

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Facility is without hot water.
Facility is without heat.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to initiate and deliver the findings for the above complaint’s allegations. LPA met with Facility Administrator Channe Carlos who was informed of the purpose of my visit and the allegations listed above. The investigation consists of direct observations, records review, regarding the above allegations.

Allegation One: Facility is without hot water.

Licensing Program Analyst (LPA) Paola Guerrero conducted a check sampling of the facility restrooms (#1, #2, #3, #4, and #5), LPA tested the water in all restrooms which tested at temperature 113.6 F in compliance with Residential Care Facility for Elderly (RCE), state regulation 87303. Based on the evidence gathered during investigation, is Unsubstantiated; meaning that 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
03/08/2023 and conducted by Evaluator Paola Guerrero

COMPLAINT CONTROL NUMBER: 56-AS-20230308142036

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: 24	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Channe Carlos		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility has bed bugs

INVESTIGATION FINDINGS:

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5
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13

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to initiate and deliver the findings for the above complaint and allegation. LPA met with Facility Administrator Channe Carlos who was informed of the purpose of my visit and the allegations listed above. The investigation consists of direct observations, records review, regarding the above allegations.

Allegation three: Facility has bed bugs

During visit LPA conducted a room inpsection and the following observations were made.
Building Two (B2) Room#8, and Room#9 and Room#10 bed bugs were observed on matress sheet protectors. S#1 stated facility sprays to mitigate the spread of bed bugs, however, the facility is not treated professionally by an exterminator for bed bugs. Based on the evidence gathered during investigation, the above allegation is Substantiated.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 56-AS-20230308142036

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE	FACILITY NUMBER: 366409921
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/07/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee will have a professional exterminator come to the facility and address the infestation of bed bugs. Proof of exterminator visit and plan to be sent to LPA Guerrero by 4/7/23.
	8 9 10 11 12 13 14	Based on observations, the licensee failed to esnsure that the facilty is keept clean and sanitary all all times for residents, which can poses a Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 56-AS-20230308142036

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE	FACILITY NUMBER: 366409921
	VISIT DATE: 03/14/2023

NARRATIVE

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A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations 87303(a) from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.
An exit interview was conducted, and a copy of this report along with the appeal rights were discussed and provided to Facility Administrator Channe Carlos

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 56-AS-20230308142036

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE	FACILITY NUMBER: 366409921
	VISIT DATE: 03/14/2023

NARRATIVE

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Allegation two: Facility is without heat.

Licensing Program Analyst (LPA) Paola Guerrero conducted a check sampling of the facility heating system and observed that heating system was in despair. S#1 stated that quotes to repair heating system have been initiated for heating system repair. LPA observed portable heaters in building one (B1), rooms (#1, #2, #3, #4). LPA also observed portable heaters in building two (B2) (#5, #6, #7, #8, #9, #10, and #11). As temporary usage while heating system gets repaired. Based on the evidence gathered during investigation, is Unsubstantiated; meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to the administrator Channe Carlos at the end of the visit

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola Guerrero	TELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5