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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366409921
Report Date: 08/26/2021
Date Signed: 08/26/2021 11:45:36 AM



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
01/19/2021 and conducted by Evaluator Christine Le
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210119110834
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: 20DATE:
08/26/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rosie RiveraTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not maintaining a comfortable room temperature for resident
Resident does not have access to a sink
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to investigate the above allegations. LPA met with caregiver Rosie Rivera. LPA spoke with the administrator over the phone.

LPA toured the facility, conducted interviews, and reviewed facility files. The first allegation indicates that staff did not maintain a comfortable room temperature for Resident 1 (R1). LPA was informed that in December 2020 - January 2021 R1 had to isolate due to COVID-19. R1 was placed in a isolation room away from the other residents. Interviews with the resident and staff reported that the room temperature was comfortable and the staff brought a heater/fan upon request. The facility staff also opened R1's windows to increase ventilation in the room. The second allegation indicates that during isolation R1 did not have access to a sink. Interviews with the resident and staff reported that R1 used a bathroom down the hall and had access to a sink. R1 also had a portable commode and sanitizing wipes in the isolation room to use as an additional option.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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 2
Control Number 18-AS-20210119110834
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: 08/26/2021
NARRATIVE
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Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the caregiver.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2