MOUNTAIN VIEW CENTER

Official classification

Type B

Official code

87468.1(a)(12)(13)

Regulation authority

CCR

What the official deficiency says

(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.

Official plan of correction

The facility shall ensure residents’ rights to keep and use their own personal possessions and to always have individual access to storage space for private use. The Licensee/Administrator may request a facility wide waiver for locks for review.

Deadline recorded: Feb 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(6)

Regulation authority

CCR

What the official deficiency says

(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.

Official plan of correction

The facility shall ensure residents’ rights to make daily life choices, including access to personal belongings. The Administrator shall submit a written plan describing how resident personal rights will be protected. Effective immediately, resident closet locks shall no longer be used, and the Administrator shall submit written confirmation that the locks have been discontinued.

Deadline recorded: Jan 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee, will send LPA, log indicating the washing of all resident bibs: staff name, date and time and number of bibs washed for 8 days. Licensee will also send LPA a copy of receipt of purchase of additional bibs by POC date.

Deadline recorded: Nov 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(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.

Official plan of correction

Administrator will certify plan by 06/29/25 that indicates how the facility will comply with this regulation. Plan must be received by 06/29/25. Proof of staff re-training on this regulation must be received by 7/7/25 via email to LPA Ramirez.

Deadline recorded: Jun 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

Administrator will give provide staff and direct staff personnel, training for understanding the care as listed in the residents’ careplans and residents’ personal rights by due date 11/08/24. Administrator will send a letter to licensing indicating Licensee has read and will comply section 87468 by 11/02/24.

Deadline recorded: Nov 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will give direct staff personnel, training for fall precautions, emergency procedures, reporting procedures by due date 11/08/24. Administrator will send a letter to licensing indicating Licensee has read and will comply section 87465 by 11/02/24.

Deadline recorded: Nov 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(4)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will give caregiving staff and direct staff personnel, training for understanding the care as listed in the residents’ IPP (Individual Program Plan) and residents’ personal rights by due date 10/25/24. On 10/11/24:Proof of correction was provided with Staff In-Service training for Falls,Resident Care, precautions and fall precautions, emergency procedures, hospice care.

Deadline recorded: Oct 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87458.2(4)

Regulation authority

CCR

What the official deficiency says

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.

Deadline recorded: Sep 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Cleared during visit. The department was provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.

Deadline recorded: Feb 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Licensee shall review section 87211 and provide a signed statement to the department by the POC date indicating the Licensee understands and will report to the department and Resident's authorized representatives of similar incidents which may occur in the future.

Deadline recorded: Feb 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Cleared during visit. The department was provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.

Deadline recorded: Jan 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator was called and agreed to send a written statement that facility will report all communicable/contagious diseases to CCL in a timely manner.

Deadline recorded: Aug 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

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:

Official plan of correction

Facility Administrator to ensure each bed is equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. LPA Irra conducted tours of this facility on 04/14/22, 04/28/22, 05/11/22, 05/26/22 and 06/08/22 and did not observe any beds to be placed on the floor. DEFICIENCY CORRECTED.

Deadline recorded: Jul 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

THIS IS A CONTINUATION OF ABOVE. (A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for matresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. This standard is not met as evidence by: LPA Almaraz observed R-2’s bed to be on the floor during the virtual tour conducted on 11/30/2020. Staff interviews revealed R-2’s bed was on the floor due to R-2 being a fall risk.

Official plan of correction

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Deadline recorded: Jul 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.38(b)(1)

Regulation authority

HSC

What the official deficiency says

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.

Official plan of correction

Facility will provide proof to the department that all residents' responsible parties and the Ombudsman have been notified in writing of the Accusation.

Deadline recorded: May 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator to provide a letter from licensee indicating licensee has read and will comply with section 87468.1 (a) (3). Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse by POC due date.

Deadline recorded: Apr 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Cleared during visit. Administrator provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.

Deadline recorded: May 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date.

Deadline recorded: Nov 4, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will ensure to report any cases of contagious diseases/infections to CCL immediatelty and provide all cross reporting information made to other agencies. Administrator will submit a plan stating what actions/steps will be taken when there is a case in the facility via fax by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date.

Deadline recorded: Nov 4, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

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 facility allowed staff members to tie residents with bedsheets onto the back of their wheel chairs were it was not reachable for residents to un tie themselves.

Official plan of correction

Administrator will ensure no residents are tied with bedsheets and will conduct personal rights training with all staff. Administrator will provide proof of personal rights training conducted by POC due date. Administrator will submit proof via fax only to LPA.

Deadline recorded: Nov 5, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will ensure to report any cases of contagious diseases/infections to CCL immediatelty and provide all cross reporting information made to other agencies. Administrator will submit a plan stating what actions/steps will be taken when there is a case in the facility via fax by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator shall ensure that all residents using a Gerry chair have an order prior to using the chair and will keep a copy of the order on their file. The facility will also request and submit a plan if they plan on using the chair for residents who do not have an order in place. Administrator shall read section 87608 of the CCR and submit a written, signed statement stating they have read and understood the section and will abide by it. Administrator will fax documents by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will reasses all current residents needs and assess new one's to determine the needs of residents and put a plan of action in place to ensure the facility has the appropriate staffing. Administrator will submit a staff schedule and a LIC 500 by POC due date via fax to LPA. Staffing agencies???

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

Administrator will ensure all resident have a bed frame and will replace or sanitize any dirty or ripped mattresses and/or box springs. Administrator will ensure extra bed frames and mattress are available on the premesis by POC due date and will submit proof via fax to LPA.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(D)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator will purchase extra hygiene and ensure each resident has their own personal hygiene and ensure staff have access to the supply when needed. Administrator will submit picture of supply available to LPA via fax only by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87415(a)(2)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

Administrator will ensure at least 2 staff are on shift when there is more than 14 residents at the facility or they determine they need 2 caregivers based on the residents needs. Administrator will send a signed statement stating their plan of action by fax by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

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.

Official plan of correction

Administrator shall ensure that all residents using a Gerry chair have an order prior to using the chair and will keep a copy of the order on their file. The facility will also request and submit a plan if they plan on using the chair for residents who do not have an order in place. Administrator shall read section 87608 of the CCR and submit a written, signed statement stating they have read and understoof the section and will abide by it. POC due by 11/01/2021.

Deadline recorded: Nov 1, 2021. A deadline is not proof that correction was completed.