366409921-10-20-2023-18-AS-NBRN-CXMRGB-20231116120028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:32:49 PM

Unsubstantiated

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
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2021 and conducted by Evaluator Anna Bueno

COMPLAINT CONTROL NUMBER: 18-AS-20210505121329

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:	10/20/2023
		UNANNOUNCED	TIME BEGAN:	12:39 PM
MET WITH:	Nenita "Joney" Carlos		TIME COMPLETED:	02:34 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not follow resident's care plan.
Facility did not transport resident to medical appointments.
Facility changed resident's choice of physician(s).
Facility had pests.

INVESTIGATION FINDINGS:

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

Licensing Program Analysts (LPA) Anna Bueno, Magda Malcore, and Bianca Wolcott conducted a subsequent unannounced visit to the facility to continue the investigation the above mentioned complaint allegations and deliver findings. LPAs identified themselves to facility staff who was informed of the reason for today’s visit and contacted licensee Nenita Carlos. The Department investigation included staff and resident interviews and facility inspections.

Allegation 1: Facility did not follow resident's care plan. Interviews with resident revealed that, while they go to their own medical appointments, residents will provide copies of the summary visit to staff. Staff interviews reveal that home health service providers communicate with staff on changes to their care.
Allegation 2: Facility did not transport resident to medical appointments. Records reviewed show that some residents services that include transportation services. Interviews with residents revealed that they are able to use public transportation to get around the community or they contact transportation service provider.
Allegation 3: Facility changed resident's choice of physician(s). Staff interviews reveal that the facility does not have their own physician however, residents who are receiving home health services are visited in the facility by medical provider. Interviews with residents confirm that they have their own physicians.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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 2

Control Number 18-AS-20210505121329

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
, CA 92507

FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE	FACILITY NUMBER: 366409921
	VISIT DATE: 10/20/2023

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

Allegation 4: Facility had pests. Records revealed that the Department has been made aware that the facility has re-occurring issues with pests. Additional records reviewed confirmed the facility is receiving ongoing, scheduled pest control service.

Based on the information obtained during the investigation, the allegations are therefore UNSUBSTANTIATED. A finding of unsubstantiated means that, although the allegations 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 was reviewed with and a copy was provided to Joney Carlos.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2