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Inspection visit

complaint

MOUNTAIN VIEW CENTERLicense 1978016052 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

LPA interviewed current and former staff #1-15 and #17-18 along with Witness #19 telephonically on the following dates; 12/29/2020, 2/9/2021, 2/11/21, 2/12/21, 3/16/21, 3/23/21, 4/6/21 and 4/16/21. On 11/2/2021, LPA's requested copies of additional residents records. Investigator Brian Slatic conducted interviews with current and former staff, family members, and residents in regards to allegation #1. The investigator also obtained records for residents. The investigation revealed the following: In regards to allegation, " Resident was sexually assaulted while in care ," During the course of the investigation, the investigator obtained information from individuals who personally witnessed many of the alleged actions and behaviors of Resident #9. Former staff members report seeing Resident #9 touch, fondle and rub female clients on their breasts and vaginal areas. Resident #9 was found in another residents room, while the other resident had their pants down. Resident #9 was found in the bed of a female resident and caught taking a female dementia resident to the back area of the facility. Resident #9 also attempted to sexually assault a female resident while under the influence of drugs. Multiple staff informed Staff #1, the Administrator at the time of the incidents. However, no substantive action appeared to have been taken to stop the behaviors and residents continued to be victimized by Resident #9. There is no information or evidence that any of these incidents were reported to Community Care Licensing (CCL) or other agencies. In regards to allegation, "Resident was exposed to scabies while in care" it was alleged a few residents had scabies at the facility. It was also alleged staff was not notified or given proper instructions on handling contagious residents. Records reviewed revealed Resident #8 was diagnosed with scabies on 8/25/2020, Resident #6 on 8/27/2020 and Resident #13 sometime later that year. Interviews with staff revealed that they were never trained on how to handle residents with scabies. Staff #1, who was the administrator at the time stated that Resident #6 and #8 did in fact have scabies. Per staff #1 both residents were room mates. Interviews with staff stated that Resident #8 had scabies first and later gave it to Resident #6. Per Staff #1, hospice said it was not scabies and later determined that it was. It was never reported to CCL. Staff #1 stated the Licensee, staff and families were notified. LPA received documents on todays visit from the County of Los Angeles Public Health being notified and a case being opened. Based on records reviewed, evidence, and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies cited under California Code of Regulations Title 22. Immediate civil penalties of $500 is being issued. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49 (f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000). An exit interview was conducted with Assistant Administrator, Laura Hernandez and caregiver Elvira Cortez, hard copy of this report was provided along with appeal rights.

Citations

7 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87211(a)(1)(D)Type B

    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 diagnoses 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(a)(3)Type A

    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(a)(3)(D)Type B

    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(a)Type B

    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(a)(2)Type B

    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

  • 87468.1(a)(2)Type B

    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(a)(3)Type B

    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.

FAQ · About this visit

Common questions about this visit

What happened during the November 3, 2021 inspection of MOUNTAIN VIEW CENTER?

This was a complaint inspection of MOUNTAIN VIEW CENTER on November 3, 2021. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to MOUNTAIN VIEW CENTER on November 3, 2021?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.