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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366409921
Report Date: 06/21/2021
Date Signed: 06/21/2021 02:05:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
366409921
ADMINISTRATOR:ILAGAN, ALEXANDERFACILITY TYPE:
740
ADDRESS:9073 OLIVE STTELEPHONE:
(909) 822-5174
CITY:FONTANASTATE: CAZIP CODE:
92335
CAPACITY:24CENSUS: 24DATE:
06/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Channe Carlos - AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility in investigate allegations related to a complaint (#18-AS-20210505121329), during which LPA Colvin observed the following deficiencies regarding medication:

During LPA Colvin's review of the facility's records for past resident (R1), LPA Colvin observed that R1 was being administered over the counter (OTC) medications (such as Vitamin D, Acetaminophen, and CranRich) daily, without a medication order from a physician. It is important to have a medication order from a physician for any OTC medications, as is required by Title 22 Regulations, as certain OTC medications may interfere with prescribed medications, or be dangerous to a resident based on their medical conditions. LPA Colvin did not observe anywhere in the medical paperwork for R1 that R1's doctors were aware of R1 taking this medication daily. Deficiency cited.

Lastly, during LPA Colvin's reconciliation of the medications prescribed and the medications administered for R1, LPA Colvin failed to observe a Centrally Stored Medication Log for any month that R1 was residing at the facility. While the Medication Administration Record (MARs) did have some of the information for most of R1's medications, the information was insufficient for what is required by Title 22 Regulations in order to ensure a complete and accurate record of all medications prescribed to and administered to each resident. Deficiency cited.

Due to LPA Colvin's observations, deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Channe Carlos.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (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.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

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Incidental Medical and Dental Care: (e) For every prescription and nonprescription PRN medication...there shall be a signed, dated written order from a physician...maintained in the residents file...Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage.
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This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation in at least three (3) OTC medications for R1. Staff were administering OTC medications to R1 without a doctor's order. This posed an immediate health and safety risk to R1.
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physician's order for the OTC medications prior to resuming administration of them. Licensee may self-certify to LPA Colvin once the audit is complete. Self-certification to be submitted to LPA Colvin by Plan of Correction date of 6/25/21.
Type B
07/05/2021
Section Cited

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Incidental Medical and Dental Care: (h) The following requirements shall apply to medications...: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... and includes: (B) The name of the prescribing physician.
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This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the regulation with at least one (1) resident (R1). LPA Colvin reviewed the entirety of R1's file and did not observe any Centrally Stored Medication Log. This posed a potential health and safety risk to R1.
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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: 06/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2021
LIC809 (FAS) - (06/04)
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