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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 05/12/2025
Date Signed: 05/12/2025 02:34:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
05/05/2025 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250505153330
FACILITY NAME:MOUNTAIN VIEW RESIDENTIAL CAREFACILITY NUMBER:
366409921
ADMINISTRATOR:ILAGAN, ALEXANDERFACILITY TYPE:
740
ADDRESS:9073 OLIVE STTELEPHONE:
(909) 822-5174
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:24CENSUS: 21DATE:
05/12/2025
UNANNOUNCEDTIME BEGAN:
11:18 AM
MET WITH:Facility Staff Rosy RiveraTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is in disrepair.
Facility is unsanitary.
INVESTIGATION FINDINGS:
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On 05/12/2025 Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility to
deliver findings for the allegations stated above. LPA met with Facility Staff-Rosy Rivera and explained the reason for the visit.

During today’s visit, LPA Singh conducted interviews with residents, conducted interviews with staff, and
requested documents.

First Allegation: Facility is in disrepair
During visit LPA conducted a room inspection and the following observations were made.
Building #1 (B1) and Building#2 (B2) were in disrepair. LPA Singh toured the facility and bathrooms were in disrepair observed leaking faucet in front house (right side bathroom facing down hallway) and bathroom in disrepair in the second (back) house still not fixed.LPA Singh observed broken doors and broken window screens of building#2. No repair records available pertinent to this allegation.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
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 3
Control Number 56-AS-20250505153330
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE
FACILITY NUMBER: 366409921
VISIT DATE: 05/12/2025
NARRATIVE
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Based on the evidence gathered during investigation, the above allegation is Substantiated.

Substantiated 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, Maintenance and Operation 87303 (a), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

Second Allegation: Facility is unsanitary.

Six(6) out of Six(6) Residents stated housekeeping visits facility once a week and bathrooms are in unsanitary condition. Bedrooms were not clean, moldy and smells of odor present in the bedroom. Pile of unwashed laundry observed by the LPA outside Building#1 back door. Outdoor area was cluttered with gardening tools.



Based on the evidence gathered during investigation, the above allegation is Substantiated.

Substantiated 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, Maintenance and Operation 87303 (a), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.


An exit interview was conducted where this report LIC 9099, LIC9099 C and LIC 9099D and Appeal Rights were discussed, and a copy was provided to Facility House manager Rosy Riverra.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20250505153330
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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: 05/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2025
Section Cited
CCR
87303(1)(f)
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Maintenance and Operation: (1)(f) The facility shall be clean, safe, sanitary and in good repair and free of leaks 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:
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Facility Administrator/Licensee will have professionallly clean Floor surfaces in bath, restrooms and other areas in sanitary and odorless condition and email training of the staff to LPA Singh by the POC due date 5/13/2025.
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Based on observations, the licensee failed to esnsure that the facilty is kept clean and sanitary all all times for residents, which can poses a Health, Safety, or Personal Rights risk to persons in care.
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Type B
05/13/2025
Section Cited
CCR
87303(a)
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Maintenance and Operation: (a)(f) 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:
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Facility Administrator/Licensee will have all repair done-doors,blinds fixed and email invoice to LPA Singh by the POC due date 05/19/2025.
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Based on observations, the licensee failed to esnsure that the facilty is in good repair at all times, which can poses a Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3