366409921-6-21-2021-18-AS-NBRN-CXRTB2-20231120133421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 06/21/2021
Date Signed: 06/21/2021 02:09:10 PM

Unfounded

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
06/15/2021 and conducted by Evaluator Crystal Colvin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210615162542

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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Resident sustained a fracture while in care

Resident sustained multiple falls while in care

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 "Resident sustained a fracture while in care": 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, the injury occured at the location next door, which is not part of the licensed facility. Therefore, based on interviews and record review, the allegation of "Resident sustained a fracture while in care" is UNFOUNDED.

Regarding allegation "Resident sustained multiple falls while in care": LPA Colvin interviewed familiy members of R1 and was informed that the falls R1 had only occured on location at the Independent Room & Board.

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)

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Control Number 18-AS-20210615162542

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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The Independent Room & Board is next door to the facility and not included in the facility's license, nor is it under the jurisdiction of Community Care Licensing. Therefore, based on interviews conducted by LPA Colvin, the allegation of "Resident sustained multiple falls while in care" 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)

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