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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 08/24/2023
Date Signed: 08/24/2023 12:45:02 PM

Substantiated


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
07/11/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230711142641
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: 24DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joney CarlosTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Facility staff does not ensure hallways used by residents are clear from tripping hazards
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Manager Joney Carlos and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Facility staff does not ensure hallways used by residents are clear from tripping hazards. LPA, Fire Marshal, along with Assistant Building Official (ABO), conducted a walkthrough of the facility and observed extension cords running from the facility laundry room over to Building #2, LPA oserved commercial power outlet connected to several appliance outlets in Building #2 which can be a potential fire/and tripping hazard for residents in Building #2; Throughout the walkthrough LPA observed ten (10) power outlets being utilized all throughout building #2. LPA asked Staff #1 about the issue regarding the power outlets around the facility S#1 stated that facility is working on getting their electrical panels repaired.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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 4
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
07/11/2023 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230711142641

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: 24DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joney CarlosTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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2
3
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9
Licensee does not ensure residents' rooms have lighting.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Manager Joney Carlos and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Licensee does not ensure residents' rooms have lighting. LPA conducted a walkthrough of the facility (building #2, and building # 3) at the time of the walkthrough LPA observed lighting to be in each building along in every room, and bathroom. Based on the evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.

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 Joney Carlos at the end of the visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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 4
Control Number 56-AS-20230711142641
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: 08/24/2023
NARRATIVE
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Throughout the walk-through LPA observed that building #2 did not have operating smoke detectors in residents’ rooms which a 24-hour corrective action notice was given. Based on the evidence gathered during investigation, the above allegation is Substantiated. This complaint is also a cross referenced to CC# 56-AS-20230816105227; Facility electric panels are in disrepair.

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 Maintenance and Operation, 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) was discussed, and a copy was provided to Facility Manager Joney Carlos at the end of the visit

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 56-AS-20230711142641
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: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87303(a)
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 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 is not met as evidence by:
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POC Administrator will review entire regulation and will provide invoices,permits, and provide all facility corrective documentation to assigned LPA by POC date 9/29/2023
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Based on observation, interviews and record review, the licensee did not ensure Maintance and Operation was maintained, which poses an immediate 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.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Paola GuerreroTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4