366423658-4-14-2023-56-AS-NBRN-CRPT3K-20230510142229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366423658
Report Date: 04/05/2023
Date Signed: 04/14/2023 01:14:44 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
04/04/2023 and conducted by Evaluator Amber Coleman

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230404142242

FACILITY NAME:	MOUNTAIN VIEW COTTAGES-VIII		FACILITY NUMBER:	366423658
ADMINISTRATOR:	MODY, TRUPTI		FACILITY TYPE:	740
ADDRESS:	9779 RAMONA AVE		TELEPHONE:	(909) 625-1231
CITY:	MONTCLAIR	STATE: CA	ZIP CODE:	91763
CAPACITY:	6	CENSUS: 6	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Caregiver		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Mountain View Cottages VIII Facility to initiate a complaint investigation regarding the allegation listed above. LPA knocked on the door and was met by Caregiver, Marjinda Kaur, (MK) who granted LPA entry to facility. LPA was asked to sign in and have temperature taken. MK called and informed Administrator of LPA's visit. Administrator arrived later during LPA visit.

Today's visit consisted of a walk through of the facility, record review and staff and resident interviews.
During the walk through of the facility, LPA did not observe any window of the facility to be broken or compromised. During interviews, LPA learned that approximately 2 weeks ago, a resident experienced a behavioral episode. During the episode, the resident, (R1) picked up a chair in the living room and through it through the window, causing the window to shatter. On 3/16/23 a window technician was scheduled for a consult.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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 3

Control Number 56-AS-20230404142242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW COTTAGES-VIII	FACILITY NUMBER: 366423658
	VISIT DATE: 04/05/2023

NARRATIVE

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On 3/22/23 the window technician returned to the facility to replace the window. The window could not be fixed immediately due to the inclement weather. Staff denies that any resident was injured in the process. LPA did not observe any resident to have injuries due to the broken window.

LPA checked the office's log of reported incidents for the last 2 weeks and was unable to locate an incident report of the incident.

Based on observations and interviews, we have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D. A copy of this report along with appeal rights are being reviewed with and furnished to the facility representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230404142242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MOUNTAIN VIEW COTTAGES-VIII	FACILITY NUMBER: 366423658
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/13/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation - (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Administrator agrees to review regulations regarding reporting requirements and what incidents warrant an incident report. Administrator will complete a statement of understanding of this regulation by way of completing a LIC9098 within 7 business days.
	8 9 10 11 12 13 14		8 9 10 11 12 13 14
ILS	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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

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