425850070-7-21-2023-29-AS-KBUY-CU6Q24-20230728114631

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850070
Report Date: 07/21/2023
Date Signed: 07/21/2023 05:57:17 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2023 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20230717161806

FACILITY NAME:	CASA MOUNTAIN VIEW		FACILITY NUMBER:	425850070
ADMINISTRATOR:	ANDREICHENKO, VIKTORIIA		FACILITY TYPE:	740
ADDRESS:	1260 MOUNTAIN VIEW RD		TELEPHONE:	(805) 403-7455
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93109
CAPACITY:	6	CENSUS: 2	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Viktoriia Andreichenko, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not provide an authorized representative access to a resident’s records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced initial 10-Day complaint visit to address the above-stated allegation. Upon arrival, LPA met with Staff 1 (S1). At the time of the visit, there were two residents in care and one staff on duty. Viktoriia Andreichenko, Administrator arrived at approximately 11:45 am. LPA stated the purpose of the visit.
On the allegation, Staff did not provide an authorized representative access to a resident’s records: To investigate the complaint, LPA reviewed documents issued to Administrator Andreichenko for former Resident 1’s (R1’s) resident file via T-SCAN Corporation on 5/18/2023. Documents reviewed included: HIPAA AUTHORIZATION FORM, 45 CFR SUBTITLE A, SUBCHAPTER C, “DECLARATION OF CUSTODIAN OF RECORDS” to be completed by Casa Mountain View Administrator, R1’s Death Certificate stating R1’s Responsible Party; government issued photo identification of R1’s responsible party; and “Out of Compliance” Letter dated June 19, 2023 addressed to Casa Mountain View, 1260 Mountain View Road, Santa Barbara, CA 93109 requesting R1’s residential records.
Please see to 9099-C, Pg 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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 29-AS-20230717161806

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA MOUNTAIN VIEW	FACILITY NUMBER: 425850070
	VISIT DATE: 07/21/2023

NARRATIVE

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LPA reviewed a list of records requested from the facility pertaining to R1 to include any and all medical records; any and all assisted living facility records; any and all medical bills, billing statements, and billing records; any and all assisted living, facility bills, billing statements, and billing records; any and all psychiatric records, whether inpatient or outpatient; any and all X-Rays and Radiology reports; and any and all electronic, written or printed correspondence.
At the time of the visit, Administrator stated she has not sent the documents to the requesting party. Administrator further stated she received a call from the requesting party yesterday (7/20/2023) at 11:57 am asking for an update on the documents requested. Administrator stated she told the caller that she would send the requested documents on Wednesday, July 26, 2023. During today’s visit, Administrator stated she will send the documents as requested by the end of the day, today.

Based on the information obtained, the allegation “Staff did not provide an authorized representative access to a resident’s records” is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to 9099-D).

Exit interview conducted, deficiencies cited, and the report and appeal rights issued during today’s visit.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230717161806

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA MOUNTAIN VIEW	FACILITY NUMBER: 425850070
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/24/2023 Section Cited CCR 87506(c)(1)	1 2 3 4 5 6 7	87506(c)(1) Resident Records: The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to send requested documents to requesting party no later than 7/22/2023. Administrator agrees to send LPA via email proof that documents were provided to the requesting party no later than 7/24/2023.
	8 9 10 11 12 13 14	Based on interview and records review, the licensee did not comply with the section cited above as R1’s records were not provided to R1’s Responsible Party and/or designated representative which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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