Mountain View Center

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. (13) To have access to individual storage space for private use.This requirement is not met as evidenced by:It was observed the facility maintains locks on resident closets prohibiting access.

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility.

87468.1 (a)(2) Personal Rights of Residents in All Facilities(a) Residents...shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: During inspection, LPA observed that (4) out of (6) resident bibs had food stains from the breakfast meal and according to staff, were going to be used again by residents for the lunch meal service.

Based on observation, bathroom#8 water temp measured over 120 degree F, the licensee did not comply with the section cited above in 4 out of 4 which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, in-service training logs did not document training hours, the licensee did not comply with the section cited above in 37 out of 37 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, signal system was not turned on during inspection, the licensee did not comply with the section cited above in 37 out of 37 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, S3 and S4 did not have documentation of required annul training hours, the licensee did not comply with the section cited above in 37 out of 37 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

(a) In addition to the rights listed in Section 87468.1,residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, and competency to meet their needs. This requirement was not met as evidenced by: staff failed to seek medical attention for 6 1/2 hours for R1 via ambualnce service for medical treatment. This poses immediate Health & Safety, or Persons Rights risk to persons in care.

87468.2(a)(4) Addtional Personal Rights of Residents in Privately Operated Facilities. (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Staff did not asses R#3 for injury after fall and staff didnot follow R3's careplan

87465(a)(1) Incidental Medical and Dental Care.(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Resident not receiving timely medical assistance.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not being met as evidenced by:Based on record review, facility person(s) responsible for reviewing and implementing a residents Fall Care Plan, failed to give proper instructions to the residents’ caregiving staff. Resulting in the resident sustaining injuries. As indicated in SIR 09/01/23 and hospital report dated 09/04/23.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities.(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met evidenced by:Based on record review, the findings indicate that on 09/01/2023, Facility person(s) responsible for giving clear instructions and explanations of R3’s Fall Care Plan to the facility staff and to R3’s caregivers, resulting in R3’s injuries sustained.

Based on observation, canopy covering was observed to be torn, the licensee did not comply with the section cited above in 37 out of 37 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment... which shall include a reassessment of the resident’s dementia care needs.This rquirement was not met as evidenced by: Based on LPA's observation and interview, the licensee failed to obtain an annual medical assessment/Physician's Report for R2 as required, which poses a potential Health, Safety, or Personal Rights risk to persons in care.

87555 General Food Service Requirements(b) The following food service requirements shall apply:(26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.This requirement was not met as evidenced by: Based on LPA's observation, there was an insufficient amount of the required 2-day persihable foods for the amount of residents in care, which poses an immediate Health, Safety, or Personal Rights risks to persons in care.

Based on observation, the licensee did not comply with the section cited above, (38) out of (38) residents which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed debris on the side of the back building that are accessible to residents, visitors and staff. The following items were observed: (1) unsecured tall ladder, (2) large air conditioning units, (6) metal-like framing items, a shed inside the packaging, (1) roll of insulation, (1) plywood, (1) wooden pallet, (2) trays, (1) Geri Chair and (6) wheelchairs (of which 1 appears to be disassembled).

Based on facility administrator interview, the licensee did not comply with the section cited above, (38) out of (38) residents which poses an immediate health, safety or personal rights risk to persons in care. During today's visit, staff were unable to provide proof of liability insurance coverage

87555 General Food Service Requirements:(b) The following food service requirements shall apply:(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.This requirement is not met as evidenced by: Based on LPA observation, food items were not properly covered which poses an potential health and safety risk to residents in care.

87303 Maintenance and Operation (i) Facilities shall have signal systems... (1)All facilities licensed for 16 or more and all residential facilities having separate floors...shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location...This requirement is not met as evidenced by: Based on observation and interview, the facility did not have a working signal system for residents to alert staff which poses a potential health and safety risk to residents in care.

87211 Reporting Requirements(a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: There are no records that indicate the facility notified R#1's authorized representative that R#1 had an un-witnessed fall on 09/08/20.

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement is not met as evidenced by: Based on complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the timeframe of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated.

87463 ReappraisalsThe pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition...This requirement is not met as evidenced by: LPA observed that R1 did not have a reappraisal to update her declining mental/ health issues, which poses a potential Health, Safety or Personal Rights risk to the residents in care.

87224 Eviction Procedures(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in...This requirement is not met as evidenced by: Based on LPA interviews and record review, the administrator refusal to accept R1 back to the facility upon discharge from hospital and not providing R1 with a 30 day eviction notice which poses a potential Health, Safety or Personal Rights risk to the residents in care.

87466 Observation of ResidentThe licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals un met needs.This requirement is not met as evidenced by: Based on interviews with staff which indicated that staff noticed a change in R1 after time of admission but did not conduct a reassessment due to R1 continous refusal, which poses a potential Health, Safety or Personal Rights risk to the residents in care.

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement is not met as evidenced by: Based on complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the timeframe of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated.

Based on observation, the licensee failed to comply in the section above in that LPA observed the CCL "Let us no" complaint poster posted. However, the poster measured 8" x10" as opposed to the required measurement of 20" x 26" as per Title 22; which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observatio, the licensee failed to comply with the section above in that restroom in Wing #2 water temperature measured at 123*. Restroom between room #2 and room #3 water temperature measured at 124.5*. Restroom between room #6 and room #7 water temperature measured at 122.3*. Restroom between room #8 and room #9 water temperature measured at 124*. Restroom between room #18 and room #19 water temperature measured at 103.2*. Restroom between room #14 and room #15 water measured at 100.4*; which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section above in that the signal system is non-operational throughout the facility. Per Administrator, the signal system has been out of service for approximately (2) months. Per Administrator, Residents that are able to request for assistance were given a hand held bell to use; which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as S-4 First Aid/CPR Certificate expired which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in S-5/Cook did not have a current Food Handling Training Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that R-1 (room#8), R-5 (room #6), R-9 has oxygen concentrators inside their bedroom but did not have oxygen in use signage; which poses/posed a potential health, safety or personal rights risk to persons in care.

87411(a) Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on observation at approximately 10:04 AM resident (R1) eloped out of the facility after exiting the memory care unit through the unlocked front door exit without staff knowledge. Staff did not ensure the front door was closed properly. This posed an immediate safety risk to this resident in care.

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to ... Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:Based on LPA observation resident (R1) eloped to the main street without staff knowledge. This poses an immediate Health and Safety risk to residents in care.

Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency. (D) Any incident which threatens the welfare, safety or health of any resident. This deficiency was evidenced by the following: The facility had (3) residents diagnosed with scabies and did not report it to CCL. A case was open with the County of Los Angeles public health, CCL was not notified.

Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:

Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50.This deficiency was evidenced by the following: Accusation is dated 4/8/22 and Administrator confirmed responsible parties and Ombudsman have not been notified in writing.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature......This requirement was not met as evidence by: The investigation revealed information from staff #24 and resident's family who personally witnessed many of the actions and behaviors of resident #7. Former staff members reported seeing resident #7 touch, fondle and rub female residents on their breasts and vaginal area. Resident #7 was found in another resident's room while resident #7 pants were down and resident #7 was also found in the bed of a female resident and was caught taking a female dementia resident to the back area of the facility. Resident #7 also attempted to sexually assault a female resident while under the influence of a substance. Despite, staff #24 being aware of resident #7 inappropriate sexual actions and behaviors with facility residents, no substantive action was taken by staff #24 to stop resident #7 behaviors and facility residents continued to be victimized by resident #7.

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement is not met as evidenced by: Interviews with staff stated that Resident #9 had scabies first and later gave it to Resident #3. Per staff #24, hospice agency said it was not scabies and later determined that it was. The facility did not report scabies to Community Care Licensing. former administrator stated the Licensee, staff and families were notified of the outbreak. During the 04/13/21 site visit, LPA Almaraz received documents indicating that the Los Angeles County Public Health was being notified and a case was being opened.

Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. This standard is not met as evidence by: LPA toured facility grounds with Laura Hernandez and did not observe the Accusation to be posted. Ms. Hernandez also confirmed that the Accusation had not been posted.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency.....(D) Any incident which threatens the welfare, safety or health of any resident..... . This requirement was not met as by evidence:The facility had (3) residents diagnosed with scabies and did not report it to CCL. A case was open with the County of Los Angeles public health and CCL was not notified.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...... This requirement was not met as evidence by: The Administrator was notified and aware about the sexual abuse Resident #9 was doing to other residents and did not take action to mitigate the abuse.

87307 Personal Accomadations and Services (a) Living accommodations and grounds shall be related to the facility's function..... The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.... (D) Hygiene items of general use such as soap and toilet paper.This requirement was not met as evidence by: Based on in interviews conducted the facility would run out of hygiene supply and when there was some it was inaccesible to staff, specially during the night shift. Residents had to share deodorant, shampoo, soap and hair brush's.

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of..... The licensing agency may require any facility to provide additional staff whenever it determines..... .This requirement was not met as evidence by:The Administrator did not provide sufficient staff to assist all residents in care which resulted in residents not being assisted with their ADL's at times.

87415 Night Supervision(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures,.... and shall be available as indicated below to assist in caring for residents in the event of an emergency. (2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes.This requirement was not met as evidence by: Only one caregiver was on shift at night, several times and was not able to assist all residents with their ADL's

87468 Personal Rights(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidence by: The facility had dirty matresses, ripped box springs and broken closet room doors. Images also provided showed a resident sleeping on a matress on the floor without a bed frame

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need ...... The licensing agency shall be authorized to require other additional documentation.....This requirement was not met as evidence by: The Administrator was allowing staff to put residents in Gerry chairs without a physcians order in place and tying residents with bedsheets without any orders.

87608 Postural Supports(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need ...... The licensing agency shall be authorized to require other additional documentation.....This requirement was not met as evidence by: Staff at the facility were putting resident #1 in a Gerry chair and using the table tray without prior approval or physcians order.

Based on observation and record review, the licensee did not comply with the section cited above. Resident #4 and #9 had half bed rails and both had orders on file for full bed rails, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by having the exterior gate locked with a chain and pad lock, and having the side gate door locked with on both sides with with a key. Based on interviews the gate door is locked at all time along with the gate and all caregivers have a key for the gate door. No fire clearance is on file with approval and licensing did not receive a request for the intent to lock all exterior gates and doors, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above. Resident #7 and #9 had missing reapprasails for previous years. (R7) had missing reappraisals for the year of 2018 and 2020. (R9) had missing reapprasails for the years of 2017 and 2018 which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not having previous training records on file for staff in regards to Oxygen administration and handling. (R4) and (R7) records indicate they have been receiving Oxygen since 2020. The facility only had a sign-in sheet with the topic of Oxygen for the year of 2021 which poses potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interviews and record review, the licensee did not comply with the section cited above which poses posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above. Bathroom in room #4 was missing a non-skid mat which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above. Personal Rights and Community Care Licensing (CCL) "Let us no" (PUB 475) complaint poster was not present at the facility which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 10 residents did not have their medication labeled with their name which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 5 bathrooms not being withing the required range per Title 22 which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 1 out of 4 staff records reviewed did not have a health screening form which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 10 residents medications were not present at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above by not having an operable call system that alerts staff which room needs assistance which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above. Both linen closets on the left wing had what appeared to be rat droppings and bathroom in room #18 on the right side wing has a peeling boarder on the wall of the bathroom floor near the toilet which poses a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, ....provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement was not met as evidence by: Facility failed to provide Resident #1, Flurosemide 20mg on 7/27/21 at 8AM.