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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604087
Report Date: 05/15/2024
Date Signed: 05/15/2024 09:29:59 AM

Unsubstantiated


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
11/20/2020 and conducted by Evaluator Alyssa Ramirez
COMPLAINT CONTROL NUMBER: 08-AS-20201120134118
FACILITY NAME:MOUNTAIN VIEW HOME-DEL VISTA WAYFACILITY NUMBER:
374604087
ADMINISTRATOR:RUSSELL, KATRINAFACILITY TYPE:
735
ADDRESS:16350 DEL VISTA WAYTELEPHONE:
(619) 419-9938
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY:4CENSUS: 1DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee Katrina RussellTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff member mismanages residents' medication
Staff falsified documentation
Untrained staff
Staff did not provide a safe environment for clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Licensee Katrina Russell and discussed the purpose of the visit and elements of the complaint.

Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency.

It was reported to CCL that staff mismanage resident medication, staff falsified documentation, facility has untrained staff and staff did not provide a safe environment for clients.

[Continued on LIC 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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 2
Control Number 08-AS-20201120134118
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 HOME-DEL VISTA WAY
FACILITY NUMBER: 374604087
VISIT DATE: 05/15/2024
NARRATIVE
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[Continued from 9099]

Regarding the allegation, staff mismanage resident medication, staff falsified documentation and facility has untrained staff, it was reported that staff are not trained on administering medication, give clients the wrong medication and falsify entries into medication administration records. Interviews with facility staff revealed that all staff are trained on medication administration prior to administering any medication and have no concerns for falsifying records or mismanaging medication. Records review revealed that all current staff have medication training certificates in employee files. Interview with outside source revealed no concerns in regards to untrained staff and no concerns surrounding medication administration.

Regarding the allegation, staff did not provide a safe environment for clients, it was reported that there was an incident where Licensee’s daughter got into an altercation with facility staff while client’s were asleep. Interviews with facility staff revealed that no one had recollection of such an incident occurring. Interview with outside source revealed that they have no concerns in regards to the safety of the facility.

Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today.



An exit interview was conducted with Licensee Katrina Russell. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Russell whose signature below verifies receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
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