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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 06/25/2021
Date Signed: 06/25/2021 03:15:04 PM



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
02/11/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200211100252
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:
06/25/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Rosy RiveraTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
Facility staff failed to contact emergency services in a timely manner

INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA met with Caregiver, Rosy Rivera, and discussed the purpose of today’s visit. The Department investigation included records review and interviews with staff, residents, and witnesses.

In regards to allegation #1, Department staff interviewed facility staff members who stated that on 2/4/20, Resident #1 (R1) experienced an unwitnessed fall and contacted emergency services once notified that R1 had fallen. R1 was discharged from the hospital to the facility on the same day. On 2/6/20, R1 had breakfast and went back to bed. According to facility staff, they were checking on R1 often as they noticed R1 was very sleepy that day. Facility staff reported no indications that R1 required emergency medical services at that time. According to Staff #1 (S1), R1 got up from bed to have dinner. Around 6:00PM, facility staff got a phone call from R1’s Power of Attorney stating that medical transport would be at the facility around 7:00PM to transport R1 to another facility. S1 and Staff #2 (S2) then gathered R1’s belongings and got R1 up from bed
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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 4
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
02/11/2020 and conducted by Evaluator Stephanie Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200211100252

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:
06/25/2021
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Rosy RiveraTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect caused resident to fall resulting in injury
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA met with Caregiver, Rosy Rivera, and discussed the purpose of today’s visit. The department investigation included file review, interviews with staff, residents, and witnesses, and collecting pertinent records.

In regards to Allegation #1, Department staff interviewed facility staff who stated that R1 experienced an unwitnessed and accidental fall while walking out onto the patio on 2/4/20. Facility staff contacted emergency services immediately and R1 was transported to the local hospital. Department staff collected R1’s medical records which showed that hospital staff conducted a CT scan which did not show an intracranial hemorrhage. Medical records claim that R1 fell and suffered from a scalp laceration. R1 was discharged back to the facility. Department staff collected R1’s physician report and pre-admission appraisal, which did not indicate that R1 was a fall risk.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20200211100252
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: 06/25/2021
NARRATIVE
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Based on evidence obtained during the investigation, this agency has determined that the allegation, resident had a fall resulting in injury is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted where this report was discussed and a copy was provided to the Caregiver.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20200211100252
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: 06/25/2021
NARRATIVE
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to place R1 in a wheelchair. S1 and S2 noticed that R1 was faintly breathing and checked R1’s vitals. During this time, the Medical Transporter arrived and noticed R1 looked pale. S1 contacted emergency services and S2 began CPR on R1. Paramedics arrived a short time later who continued CPR and transported R1 to the hospital. The evidence collected by Department staff was not sufficient to substantiate the allegation that staff failed to contact emergency medical services in a timely manner, therefore the finding is UNSUBSTANTIATED.

Based on evidence obtained during the investigation, this agency has determined that the above allegation is UNSUBSTANTIATED; meaning that 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 where this report was discussed and a copy was provided to the Caregiver.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4