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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 06/10/2021
Date Signed: 06/10/2021 01:40:44 PM

Substantiated


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
06/01/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210601154523
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:
06/10/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Channe Carlos - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility parking lot is uneven and unsafe
Unlawful Eviction
Facility not stocking bathrooms with neccesary supplies
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived to initiate an investigation into the above complaint allegations. LPA Colvin met with Administrator Channe Carlos. LPA Colvin advised Channe Carlos of the purpose of the visit and requested to review resident records and tour the facility.

During today's visit, LPA Colvin interviewed Administrator Channe Carlos and several residents at the facility regarding some of the allegations of the complaint. LPA Colvin additionally toured the facility and reviewed resident records, staff records, and other facility records. Below is a summary of the findings of this complaint:

Regarding allegation "Facility parking lot is uneven and unsafe": LPA Colvin toured the facility and observed multiple areas of the parking lot and outside walkways that were cracked and uneven. The areas of the outside walkway which still present a hazard includes areas where sections of the pavement are at least one inch in difference between height for one section of pavement and the following section of pavement. The sections of pavement run horizontally across the majority (if not all) of the walkway, so they must be crossed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
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 7
Control Number 18-AS-20210601154523
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: 06/10/2021
NARRATIVE
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Additionally, at least one resident (R1) has fallen on the pavement due to the abrupt changes between sections of pavement. Due to observations made by LPA Colvin, the allegation of "Facility parking lot is uneven and unsafe" is SUBSTANTIATED.

Regarding allegation "Unlawful Eviction": LPA Colvin reviewed the file for multiple residents and asked the Administrator about recent evictions notices being given to residents. LPA Colvin reviewed the file for R1, who was issued a 30-day eviction notice on 6/1/21 and interviewed the Administrator regarding the situation surrounding the eviction. LPA Colvin observed that the reason on the eviction notice for the eviction was that the facility was unable to meet the resident's needs. Title 22 Regulations require that if a resident is to be evicted for the facility not being able to meet their needs, that a reassessment must be done first to document these changes. LPA Colvin observed that R1's Needs & Services Plan was updated in November 2020, with no mention of any needs of the resident which the facility cannot meet. LPA Colvin additionally reviewed staff notes and recent Incident Reports and again did not find any documentation by the facility of needs that cannot be met. Administrator Channe advised LPA Colvin that she does have documentation, but that it is not in the file or readily available to provide to LPA Colvin at this time. Due to the facility not complying with Title 22 Regulations in completing a re-assessment of R1 prior to issuing an eviction notice for not being able to meet their needs, the allegation of "Unlawful Eviction" is SUBSTANTIATED.

Regarding the allegation "Facility not stocking bathrooms with necessary supplies": LPA Colvin conducted a tour of the facility, which included two resident bathrooms, one in the middle building and one in the last building. LPA Colvin observed that neither restroom had paper towels nor any other means for residents to dry their hands after washing. LPA Colvin interviewed multiple residents and was informed that they are not supplied with paper towels other than what is stocked in the bathrooms. Due to LPA Colvin's observations of two bathrooms not being stocked with paper towels and the residents' denial of any other means to dry their hands, the allegation of "Facility not stocking bathrooms with necessary supplies” is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 Ds. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports, forms, and appeal rights were provided to Administrator Channe Carlos during the exit interview.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20210601154523
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2021
Section Cited
CCR
87307(a)(3)(D)
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Personal Accommodations and Services: (a) Living accommodations...shall be related to the facility's function...The following...shall apply:(3)...supplies necessary for personal care and...adequate hygiene practice shall be readily available...(D) Hygiene items of general use such as soap and toilet paper.
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Licensee agrees to make and paper towels readily available to residents in the bathrooms immediately. If certain residents exhibit a behavior for misusing basic hygiene products, then the Licensee shall address this another way. Photographic proof of paper towels in bathroom to be submitted to LPA Colvin by
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This requirement was not met by: Based on LPA Colvin's observations and interviews, the Licensee did not comply with the above regulation in at least 2 resident bathrooms. LPA Colvin observed two bathrooms to not have paper towels or other means to dry one's hands. This is a potential health risk.
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the Plan of Correction date of 6/24/21.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20210601154523
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2021
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 was not met by:
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Licensee agrees to correct all areas of the outside walkways to ensure that there is no hazard to residents when walking along the facility grounds. Licensee to provide LPA Colvin with pictures of corrections by the Plan of Correction date of 6/24/21.
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Based on observations, the Licensee did not comply with the above regulation in multiple areas of the facility's outdoor walkway. LPA Colvin observed multiple areas of pavement where the sections of pavement were cracked or at various heights. This is an immedaite safety risk to all residents and staff.
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Type A
06/11/2021
Section Cited
CCR
87244(a)(4)
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Eviction Procedures: (a) The licensee may evict a resident for one or more of the reasons listed...(4) If...it is determined that the resident has a need not previously identified and a reappraisal has been conducted...licensee and the person who performs the reappraisal believe that the facility is not appropriate...
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License agrees to recend the Eviction Notice (dated 6/1/21) for R1, and document the recended eviction and provide R1 and LPA Colvin with documentation. Licensee agrees to complete a reassessment of R1 prior to re-issuing any 30-day notice for the same cause. Proof of recended notice to be submitted to
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This requirement was not met by: Based on record review and interview, the Licensee did not comply with the above regulation with one resident (R1). R1 was given a 30-day eviction notice for needs not being able to be met, but no reappraisal was done. This is an immediate personal rights violation of R1.
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LPA Colvin by the Plan of Correction date of 6/11/21.
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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
06/01/2021 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210601154523

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:
06/10/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Channe Carlos - AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
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9
Facility not providing adequate cleaning services to resident rooms
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Crystal Colvin arrived to initiate an investigation into the above complaint allegations. LPA Colvin met with Administrator Channe Carlos. LPA Colvin advised Channe Carlos of the purpose of the visit.

During today's visit, LPA Colvin interviewed several residents at the facility regarding the allegation listed above. LPA Colvin additionally toured the facility, which included multiple resident bedrooms. Below is a summary of the findings of this complaint:

Regarding allegation "Facility not providing adequate cleaning services to resident rooms": LPA Colvin toured both facility buildings which have resident bedrooms and inspected the cleanliness of multiple bedrooms in each building. LPA Colvin did not observe any noteworthy issues with cleanliness in any resident bedrooms which LPA Colvin inspected. LPA Colvin additionally interviewed seven residents during today's inspection, all of which denied any issues with staff not cleaning their bedrooms.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20210601154523
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: 06/10/2021
NARRATIVE
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Due to observations made by LPA Colvin as well as interviews conducted of several residents, the allegation "Facility not providing adequate cleaning services to resident rooms" is UNSUBSTANTIATED.

A finding of 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.

An exit interview was conducted with Administrator Channe Carlos and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7