366409921-6-21-2021-18-AS-NBRN-CXMRGC-20231116120028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 06/21/2021
Date Signed: 06/21/2021 02:03:21 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
05/05/2021 and conducted by Evaluator Crystal Colvin

PUBLIC

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:	06/21/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Channe Carlos - Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility mismanaged resident's medications.

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 of the purpose of the visit and requested to review resident records. Below is a summary of LPA Colvin's findings:

Regarding allegation "Facility mismanaged resident's medications": LPA Colvin reviewed the file for resident (R1) including Medication Administration Records (MARs) Log for the months of March 2019 - June 2019, as well as accompanying medical records in file. LPA Colvin observed numerous medication errors in R1's file, including seven (7) medications in March which were not started until 3/10/19 when the order was made by the doctor on 3/2/19, the same date the resident moved into the facility. LPA Colvin observed that there were several other medications noted on the MARs Log which had been started on 3/2/19. Additionally, one of the medications (nitrofurantoin) was noted on the MARs Log to be discontinued as of 3/14/19, but there are no supporting documents from a medical doctor with this order. In fact, the medical paperwork from R1's doctor visit on 3/14/19 shows for this medication to be continued.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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

LIC9099 (FAS) - (06/04)

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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
05/05/2021 and conducted by Evaluator Crystal Colvin

PUBLIC

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:	06/21/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Channe Carlos - Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility did not have activities for resident.

Staff member harassed resident.

Facility mismanaged resident's banking information and food stamp card.

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 of the purpose of the visit and requested to review resident records. Below is a summary of LPA Colvin's findings:

Regarding allegation "Facility did not have activities for resident": LPA Colvin reviewed the file for resident (R1) and observed that R1 lived at the licensed facility from 3/2/19 to 8/1/19. LPA Colvin interviewed facility staff and family members of R1, and confirmed that after 8/1/19, R1 moved into the Independent Room & Board next door to the facility. According to interviews, this allegation was alledged to have been in relation to the unlicensed Room & Board next door, which Community Care Licensing (CCL) does not have jurisdiction over. Therefore, based on interviews and record review, the allegation of "Facility did not have activities for resident" is UNFOUNDED.

*Continued on LIC9099C*

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

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
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE	FACILITY NUMBER: 366409921
	VISIT DATE: 06/21/2021

NARRATIVE

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Regarding allegation "Staff member harassed resident": LPA Colvin interviewed the Reporting Party and confirmed that the allegation was reported to have taken place at the unlicensed Room & Board next door to the facility. Since CCL does not have any authority over the unlicensed Room & Board, the allegation is UNFOUNDED.

Regarding allegation "Facility mismanaged resident's banking information and food stamp card" LPA Colvin interviewed the Reporting Party and staff for both the licensed facility and the unlicensed Room & Board. All interviews confirm that this allegation stems from the R1 living at the unlicensed Room & Board, where it is alleged that R1's benefit cards were missing when family came to collect R1's belongings. Since the allegation is in regards to the unlicensed Room & Board which CCL has no jurisdiction over, the complaint is UNFOUNDED.

We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted with Administrator Channe Carlos and a copy of this report was provided.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

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
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE	FACILITY NUMBER: 366409921
	VISIT DATE: 06/21/2021

NARRATIVE

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LPA Colvin found additional medication errors on the MARs Log for R1 for the month of May 2019, wherein the MARs Log shows the facility administered potassium 10mg once a day in the morning, but the order for the medication (which is affixed to the MARs Log), shows that it should have been administered twice a day.

In the June 2019 MARs Log, LPA Colvin did not observe four of R1's medications (Nitrofurantoin 100mg, Seroquel 400mg, Prednisone 5mg, & Vraylar 1.5mg) which were noted on two after visit summaries for R1 dated 6/20/19 and 6/22/19. LPA Colvin found additional medication issues during the review of R1's records which will be addressed separately from this complaint. Based on record review, the allegation of "Facility mismanaged resident's medications" 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 deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports and forms, LIC 9099D, and appeal rights are were provided to Administrator Channe Carlos during the exit interview.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW RESIDENTIAL CARE	FACILITY NUMBER: 366409921
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/25/2021 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights...Facilities: (a) In addition to the rights listed in Section 87468.1...residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs...and competency to meet their needs.	1 2 3 4 5 6 7	Licensee agrees to have all staff who assist with administration of medication to residents to be re-trained on administering medications and record keeping/documentation. Proof of staff training to be submitted to LPA Colvin by Plan of Correction date of 6/25/21.
	8 9 10 11 12 13 14	This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation with at least 12 medications for R1 throughout March 2019 - June 2019. Medications were not administered by staff as prescribed. This posed an immedaite health risk to R1.	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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6