565801019-10-13-2020-29-AS-KBUY-BUDNRC-20201014104119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801019
Report Date: 10/06/2020
Date Signed: 10/13/2020 04:47:22 PM

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
07/30/2020 and conducted by Evaluator Lyndia Sager

COMPLAINT CONTROL NUMBER: 29-AS-20200730131158

FACILITY NAME:	MOUNTAIN VISTA MANOR		FACILITY NUMBER:	565801019
ADMINISTRATOR:	NICKIE PEREZ		FACILITY TYPE:	740
ADDRESS:	602 EAST OAK STREET		TELEPHONE:	(805) 646-6850
CITY:	OJAI	STATE: CA	ZIP CODE:	93023
CAPACITY:	38	CENSUS: 29	DATE:	10/06/2020
		ANNOUNCED	TIME BEGAN:	04:26 PM
MET WITH:	Nickie Perez		TIME COMPLETED:	04:34 PM

ALLEGATION(S):

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Facility did not meet the needs of incontinent resident
Residents hygiene needs are not being met
Facility staff make inappropriate comments

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Lyndia Sager conducted a subsequent complaint investigation to deliver final investigation findings telephonically due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures.

On the allegation: Facility did not meet the needs of incontinent resident. LPA Sager conducted an interview with resident (R1). Information obtained from (R1) finds that staff assist with toileting, showers, dressing, and transferring whenever needed. There have been times where (R1) has “had to wait for assistance but not for long, maybe 10 minutes”. (R1) states (R1) rings the buzzer if help is needed. Information obtained through interview with (R1) family member states they visit the facility frequently and have no concerns about the care and assistance (R1) receives.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Lyndia Sager	TELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

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-20200730131158

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: MOUNTAIN VISTA MANOR	FACILITY NUMBER: 565801019
	VISIT DATE: 10/06/2020

NARRATIVE

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On the allegation: Residents hygiene needs are not being met. LPA Sager reviewed random residents’ records, staff schedule and shift logs. Staff on the a.m. and p.m. shift stated they “check the residents every 2 hours or as often as needed” and respond promptly to residents’ buzzer to assist with toileting. LPA Sager reviewed shift logs, change/restroom log, monthly resident health calendar. Residents interviewed stated they had no concerns about staff assistance or toileting needs. Witnesses stated they have observed the facility to be clean and odor free and had no concerns with the hygiene or toileting needs of the residents.

On the allegation: Facility staff make inappropriate comments. LPA Sager conducted interviews with Administrator, staff, residents and witnesses. Administrator and staff denied making inappropriate comments or hearing any staff make inappropriate comments. LPA Sager conducted interviews with residents and witnesses who stated facility staff are professional and kind to the residents and had no concerns with the staff.

Based on the information obtained during the course of the investigation, the complaint allegations are deemed unsubstantiated at this time.

A telephonic exit interview was conducted with the Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Lyndia Sager	TELEPHONE: (805) 680-7683
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

LIC9099 (FAS) - (06/04)

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