374604087-9-21-2023-08-AS-DPOL-CY3QWN-20231130113213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604087
Report Date: 09/21/2023
Date Signed: 09/21/2023 12:21:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
09/01/2023 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20230901100544

FACILITY NAME:	MOUNTAIN VIEW HOME-DEL VISTA WAY		FACILITY NUMBER:	374604087
ADMINISTRATOR:	RUSSELL, KATRINA		FACILITY TYPE:	735
ADDRESS:	16350 DEL VISTA WAY		TELEPHONE:	(619) 419-9938
CITY:	EL CAJON	STATE: CA	ZIP CODE:	92021
CAPACITY:	4	CENSUS: 2	DATE:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	11:07 AM
MET WITH:	Katrina Russell, Administrator		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Staff did not supervise resident in care
Facility did not meet reporting requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close a complaint investigation regarding the above-mentioned allegations. LPA identified herself and met with Katrina Russel, to discuss the purpose of the visit and elements of the complaint.

It was alleged that staff did not supervise resident in care. Interviews revealed there was an incident that occured at the facility on August 10, 2023. There were two clients at the facility and one staff. The staff was in the kitchen trying to cook dinner and Client 1 (C1) attempted to take the knife out of the staffs hand. The client was not able to get the knife. The client nor the staff was hurt. C1 was taken to the hospital on a 51/50 hold. The other client was not in the kitchen during the incident. The staff reported the incident to the adminsitrator and they arrived shortly after (about two minutes later). The staff that was on duty supervised the client the whole time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230901100544

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MOUNTAIN VIEW HOME-DEL VISTA WAY	FACILITY NUMBER: 374604087
	VISIT DATE: 09/21/2023

NARRATIVE

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It was alleged that the facility did not meet reporting requirements. Interviews revealed
On August 10, 2023, the San Diego Regional Center (SDRC) received a report (dated 8/9/23) stating C1 had attempted to remove a knife from staff. Staff were able to call law enforcement and resolved the situation with no major incident. Interviews revealed the administrator verbally notified the case manager that C1 was actually trying to hurt them self on that day and not the staff. Interviews revealed additional but conflicting information that C1 was possibly trying to hurt another client. The report was reported and was reported timely. There is no issue of the staff not meeting reporting guidelines.

The allegations of staff did not supervise resident in care and facility did not meet reporting requirements are unsubstantiated. An exit interview was conducted with Katrina Russell, Administrator. A copy of this report and Licensee Appeal rights (LIC 9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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