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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374601634
Report Date: 03/18/2024
Date Signed: 03/18/2024 02:18:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2020 and conducted by Evaluator Daniel Pena
COMPLAINT CONTROL NUMBER: 08-AS-20201106150947
FACILITY NAME:MOUNTAIN VIEW HEALTHCAREFACILITY NUMBER:
374601634
ADMINISTRATOR:SONYA KARPALFACILITY TYPE:
740
ADDRESS:1404 JAMACHA ROADTELEPHONE:
(619) 588-8045
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:0CENSUS: 0DATE:
03/18/2024
UNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Mailed to last know address via USPS mailTIME COMPLETED:
12:04 PM
ALLEGATION(S):
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Licensee did not meet the care needs of the resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Pena sent this report to former licensee's last known mailing address via USPS certified mail.

On November 6, 2020, Community Care Licensing (CCL) received a complaint alleging the Licensee did not meet the care needs of the resident. The Department’s investigation consisted of LPA observation, interviews with pertinent residents, staff and outside sources, and facility and outside source record reviews.

A review of home health agency and facility records revealed the facility did not have a care plan in place to address and delineate responsibilities of the two entities. Resident observation notes consisted of visits by outside agency personnel. No facility documentation of Resident 1 (R1)'s was obtained regarding R1's skin condition. Furthermore, R1's Needs and Services Plan, dated July 2, 2020, did not address R1's physical conditions.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
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 5
Control Number 08-AS-20201106150947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MOUNTAIN VIEW HEALTHCARE
FACILITY NUMBER: 374601634
VISIT DATE: 03/18/2024
NARRATIVE
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It should be stated that records were reviewed which revealed R1's history of hip and neck fractures. Records revealed R1 used a front wheel walker, which indicates the resident was non-ambulatory and would not be involved in physical activities.

A Physician's Report dated 6/20/20 confirmed sip hip hemiarthroplasty, and sip left hip sub-capital neck fracture. It was also noted that the resident required "assistance getting from lying to sitting, sitting to standing, dressing bathing & eating." A needs and services plan (only signed by the licensee even though Outside Source was listed as the responsible person) indicated R1 used a front wheel walker and was "ambulatory."

Based upon review of R1's physician's report, dated 8/5/2020, it was indicated the resident was incontinent of bladder and bowel. R1 required a managed incontinence care plan to address observations of skin breakdown. Records and interviews confirm the Licensee did not conduct a reappraisal of R1 when it was determined that the resident had a change in condition.

Based on the Department’s investigation which consisted of review of pertinent records and interviews, the preponderance of evidence standard was met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. A copy of this report and Appeal and Licensee Rights (LIC 9058 03/22) were provided to the former Licensee, via USPS Certified Mail.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20201106150947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MOUNTAIN VIEW HEALTHCARE
FACILITY NUMBER: 374601634
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2024
Section Cited
CCR
1569.49
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ASSISTANCE WITH ACCESSING HOME HEALTH OR HOSPICE SERVICES; RECEIPT OF MEDICAL SERVICES - Failure to meet or arrange to meet the needs of those residents who require health-related services as specified in the resident’s written record of care...is a
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Immediate health and safety risk was removed as facility closed as of February 7, 2024. Plan of correction cleared.
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licensing violation and subject to civil penalty pursuant to Section 1569.49. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure the written record of care identified by the home health agency for one 1 of 6 residents was followed. This posed an immediate health and safety risk to residents in care.
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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: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2020 and conducted by Evaluator Daniel Pena
COMPLAINT CONTROL NUMBER: 08-AS-20201106150947

FACILITY NAME:MOUNTAIN VIEW HEALTHCAREFACILITY NUMBER:
374601634
ADMINISTRATOR:SONYA KARPALFACILITY TYPE:
740
ADDRESS:1404 JAMACHA ROADTELEPHONE:
(619) 588-8045
CITY:EL CAJONSTATE: CAZIP CODE:
92019
CAPACITY:0CENSUS: 0DATE:
03/18/2024
UNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Mailed to last know address via USPS mailTIME COMPLETED:
12:04 PM
ALLEGATION(S):
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Licensee did not meet the hygiene needs of the resident
Licensee did not meet the dietary needs of the resident
INVESTIGATION FINDINGS:
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It was also alleged, Licensee did not meet the hygiene and dietary needs of R1.

Witness interviews were inconsistent. Outside sources interviews revealed R1's hygiene needs were being met. They bathed R1 daily and had someone apply lotion. Outside sources were very aware if there were any foul odors and they never smelled any of those on R1. R1's ears had no wax build up, no nasal mucous and R1's teeth were clean. An outside source said from a hygiene stand point, the facility took care of R1. A physician came to the facility and checked resident's nails and feet. An outside source stated that the facilities' policies and procedures were designed to protect the residents. When it came to any signs of any problems. They always erred on the side of caution and they would call families and/or immediately arrange for the resident to be transported to the hospital.

A review of R1's Physician’s report dated 6/2020 read in part: Type II Diabetes, formerly on metformin – recommended to monitor glucose. No special diet indicated. Physician's Report dated 8/5/2020,
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20201106150947
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MOUNTAIN VIEW HEALTHCARE
FACILITY NUMBER: 374601634
VISIT DATE: 03/18/2024
NARRATIVE
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required a "heart healthy" diet. Licensee stated that they have a sample menu but that it changes with the requests of the resident. Resident was getting cereal most mornings with little change in the diet or dietary needs. Ice cream, eggs, sausages, French toast, waffles, hot dogs, chips, cereal were regular items from 10/1/20 through 10/27/20. For type II diabetes, no special diet was ordered and based on blood sugar reading from R1's home health agency. R1's glucose level was in the 200s, which is within normal limits for this diagnosis (according to the notes), until the resident was transferred on 10/27/20, where the blood sugar was above 250. A review of medications also saw no orders for glucose monitoring or a diabetic diet.

A review of R1's hospital discharge records dated, 6/2020, revealed no weight records. Physician's reports dated 6/2020 and 8/2020, also did not include R1's weight records. R1's home health agency also did not include weight records, nor did the facility. The only weight record noted was from R1's home health agency taken after R1 had relocated to another licensed care facility after hospitalization. Based upon record reviews, it cannot be determined R1 lost weight during their stay at Mountain View Healthcare.

The Department has investigated this complaint. Based upon records reviewed and interviews with staff and outside sources, there is insufficient information to corroborate the allegations. The preponderance of evidence standard was not met. The allegations are deemed unsubstantiated.

Based on the Department’s investigation, the preponderance of evidence standard was not met, therefore the above allegations are found to be UNSUBSTANTIATED. A copy of this report and Appeal and Licensee Rights (LIC 9058 03/22) were provided to the former Licensee, via USPS Certified Mail.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Daniel PenaTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5