Mountain View Center.

Allegation: Staff preventing residents from getting personal belongings. It was alleged R1 requested a sweater from staff member S1 and was denied. It was further alleged that R1’s closet is locked due to R1 removing clothing and creating a mess. It was also alleged that other residents have locked closets while some residents do not. The report alleges staff are preventing residents from accessing their personal belongings. During resident interviews, most residents (R2–R7) reported that their clothing is kept in their closets and stated that their closets were not locked. None of these residents reported that staff had told them they could not have their clothing or personal items. When asked whether they had concerns about staff preventing access to belongings, most residents were unable to answer. Several residents demonstrated limited ability to respond to questions, which appeared consistent with cognitive impairment. R1 reported that her closet is always locked and stated that she cannot access her clothing whenever she wants. R1 reported that staff sometimes assist her in accessing her clothing when she asks and stated that staff have sometimes told her she could not have her belongings. R1 stated that she feels “sad” when she is unable to access her belongings. R1 appeared consistent with cognitive impairment. During staff interviews, staff consistently reported that some residents’ closets are locked due to safety concerns related to cognitive impairment, including residents removing all items from closets, attempting to leave the facility with belongings, or misplacing items. Multiple staff indicated that these behaviors are frequently associated with R1 due to confusion and dementia-related behaviors. Staff generally stated that the decision to lock a resident’s closet is made or approved by administration; however, some staff reported that there was no specific directive and that staff act based on familiarity with resident behaviors. Staff reported that keys to locked closets are accessible to staff, including medication technicians, and that all staff are aware of the combination codes for coded locks. Staff stated that residents may request staff assistance to access their belongings. Several staff reported that they had not observed staff denying residents access to their personal belongings when requested. Staff were unsure whether restrictions on personal belongings are documented in resident records. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 During the visit, LPA observed resident R1’s closet to be locked. LPA also observed six (6) additional resident bedrooms with closet locks present, some of which were in use or broken. LPA observed that some residents’ closets were locked while others were not. LPA did not observe any posted signage or written notice explaining restrictions on resident access to personal belongings. The LPA reviewed R1’s admission agreement, assessments, and care plan and found no documentation authorizing restrictions on access to personal belongings. S1 confirmed no such documentation existed and stated that no waiver to lock resident closets had been requested to Licensing. No physician order or written consent was observed, and facility policies did not clearly authorize locking resident closets. The LPA attempted to contact the assigned ALW Coordinator and social worker but was unable to make direct contact and left a message with the ALW receptionist. Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Regarding: Staff forced residents to wear bibs. It is alleged that staff is forcing residents to wear bibs during mealtimes. Staff deny the allegation. Interviews with seven (7) out of (7) staff revealed that staff do not force residents to wear bibs/clothes protectors during mealtimes. Staff indicated that the bibs are placed on residents after getting consent for those who need help with feeding. Staff indicated that the bibs help prevent residents’ clothes from getting stained, particularly for those who have their food pureed. Staff further indicated that residents can remove the bib at any time during or after their meals. Interviews with (6) residents revealed that they are not forced to wear bibs during mealtimes. LPA, attempted to interview R7-R9 but R7 and R8 did not respond to LPA’s questions and R9 was not at the facility during visit. LPA, conducted observation during the lunch meal service and did not observe any staff forcing residents to use a bib while being helped with their feeding. Staff and resident interviews and LPA observation do not corroborate the allegation that residents are being forced to wear bibs. Regarding: Staff did not follow proper hand hygiene procedures when assisting residents in care. It is alleged that staff is assisting multiple residents in their room without changing their gloves between residents. Staff deny the allegation. Interviews with (7) out of (7) staff revealed that staff change their gloves between residents in care. Staff indicated that they follow proper hand hygiene and glove protocols when caring for residents. Staff further indicated that gloves are not reused between residents and that gloves are for one-time use. Staff stated that gloves are properly removed and disposed of to prevent contamination as indicated by the training they receive regarding glove use. Staff also stated that the facility has sufficient gloves for all staff to use and when supply becomes low, staff can replenish glove stations with boxes from the supply closet in the med-tech area. Interviews with (6) out of (9) residents indicated that they have no concerns about the use of gloves by staff. Three residents did not provide a statement about the use of gloves by staff. LPA inspected the facility’s glove supply and observed to have sufficient gloves for the use of staff. Further observation of the facility by LPA indicated that the facility has glove holders on the walls of both wings by resident rooms in a variety of sizes, and boxes of gloves are also kept in the bathroom and in the med-tech carts. Staff and resident interviews, and LPA observations, do not corroborate the allegation that proper hand hygiene procedures are not being followed by staff when assisting residents in care. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated . An exit interview was conducted, and a copy of this report was provided. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The investigation revealed the following: Regarding: Staff did not clean and disinfect items shared between residents in care. It is alleged that bibs are not washed and that staff is reusing them with other residents. Interviews with (4) out of (7) staff revealed that bibs/clothes protectors are used on residents during mealtimes to prevent their clothes from being stained with pureed food. Staff indicated that if bibs are observed not to be soiled during breakfast after being used on a resident, the bib is then placed on the dining room cart and saved to be used again during the lunch meal service. Staff further indicated that after lunch, staff will then place the soiled bibs removed from residents into the laundry hamper located in the dining room and the night shift will proceed to wash them and have them ready for the dinner meal service. Staff further indicated that the bibs are washed daily; however, they are washed after the second meal service by the night staff after bibs have been used for breakfast and lunch. Interviews with (2) staff further indicated that at times, it is hard to tell which bibs were used by a particular resident during breakfast and bibs may be placed on a different resident during the lunch meal service. During tour of facility, LPA inspected (6) bibs which were folded and stored on a cart in the dining room. LPA observed (4) out of the (6) bibs to have food stains. Staff indicated that the bibs inspected by LPA were going to be used again today for the lunch meal service and had not noticed that the bibs were soiled. LPA attempted to conduct interviews with (8) residents but they were unable to answer questions asked by LPA. R9 was unable to be interviewed due to being away from the facility during visit. Staff interviews and LPA observation corroborated the allegation that items are not clean and disinfected between resident use. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report and Appeal Rights were provided.

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Gabby Castro conducted an unannounced required annual inspection visit and was greeted by MedTech Elvira Cortez. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in grooming and bathing areas were measured to be over 120 degrees F. Resident bathroom#8 water temperature was measured to be 123 degrees F. LPA Ramirez will issue type A deficiency based on this observation. LPA Ramirez observed postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed non-slip mat in showers. Showers were observed to be wheelchair accessible. Food Service: LPA Ramirez observed a sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). See 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Planned Activities: LPA Ramirez observed staff conducted seated activities with residents during inspection. Facility employs a full-time activity director to plan and carry out activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed the facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. The last documented emergency drills were conducted on 05/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed an emergency food supply. Residents with Special Needs : No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices and delay egress perimeters were observed to be in working order. LPA Ramirez pulled emergency cords in rooms#4 and 7. After waiting a few minutes, staff did not respond and LPA Ramirez asked to see the location of the main signal system. LPA Ramirez and med tech Elvira Cortez observed the main signal box was not "powered on" and was unplugged. Staff advised LPA Ramirez that sometimes residents will sometimes unplug the signal system. LPA Ramirez will issue a type B deficiency based on this observation. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cart and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. Staffing: Administrator Certificate for Laura Hernandez and it expires 08/25/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. see 809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed some required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed. Staff#3 (S3) & staff#4 (S4) did not have sufficient annual required training hours on dementia, postural supports, restricted health conditions and hospice care as required by 1569.625(b)(2). LPA Ramirez observed some of the documented in-service trainings did not document the numbers of hours. LPA Ramirez will issue two (2) type B deficiencies based on this record review. Infection Control: They’re using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for forty (40) non-ambulatory, of which ten (10) may be bedridden. This facility may retain no more than twenty (20) hospice residents. The facility currently has nine (9) residents on hospice care. Resident Records/Incident Reports: LPA reviewed Resident files for four (4) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Four (4) deficiencies were issued. Exit interview conducted. A copy of this report, 809-D, and appeals rights were provided.

The investigation revealed the following: regarding the allegation “Staff did not seek medical attention for resident in a timely manner.” It is alleged facility staff did not seek medical attention in a timely manner for R1 on 03/20/2025. Staff interviews conducted by Community Care Licensing-Investigations Branch corroborated this allegation. Due to R1’s cognitive impairments, R1’s interview was unreliable. Interviews conducted revealed facility staff scheduled R1 to be transported via ambulance by First Rescue Ambulance service on 03/20/2025 at 2300 hour to seek medical attention for an injury that was not healing properly. On 03/21/2025, at 0630 hours, Administrator Hernandez arrived at the facility and was informed R1 was still at the facility and had not been transported for medical attention as scheduled. Staff waited 6 ½ hours before seeking medical attention for R1 after ambulance transportation service did not arrive at scheduled time. This poses immediate Health & Safety, or Persons Rights risk to persons in care. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. One (1) type A deficiency was cited during this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided via email. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The investigation revealed the following: regarding the allegation “Resident sustained a serious injury due to lack of care from staff.” It is alleged R1 sustained a serious injury on 03/10/2025. Staff interviews conducted by Community Care Licensing-Investigations Branch did not corroborate this allegation. Due to R1’s cognitive impairments, R1’s interview was unreliable. Records reviewed by Community Care Licensing-Investigations Branch did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED . No deficiency was cited for this allegation. Exit interview was conducted. A copy of this report was provided via email.

LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas with assistance of staff Daisy Fitter, and obtained the following documents for Residents# 1-4 (R1-R4): Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA did not observe any immediate health and/or safety concerns. Regarding the allegation: Due to staff neglect, residents fell resulting in injury, it was alleged that on 09/01/23, in the early morning, resident R3 had an unwitnessed fall and sustained injuries. Staff/Caregivers discovered R3 on the floor near the R3’s bed. Staff put R3 back in bed and staff did not notify the Facility Administrator of R3s fall. Staff did not assess R3 after the fall. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported to being aware that R3 has a history of fall and R3s family member supplied the facility with a Life Station device that would alert 911 if R3 fell in the facility, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. Resident #3 was moved to healthcare facility and was not interviewed during the investigation due to R3’s cognitive impairment. The investigation revealed that on 08/31/23, R3 fell in the facility and staff were aware of R3s fall, staff did not assess R3 for injury and did not inform the administrator of R3s fall. Additionally, staff did not seek immediate medical treatment for R3 after the 09/01/23 fall. R3 was taken for medical treatment the next day. The hospital staff assessed the R3 and observed R3 sustained multiple fractures; fracture to the left ribs, punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The facility did not properly assess R3 for injury after the R3’s fall, and it was discovered on 09/01/23 that R3 sustained serious injury. Regarding the allegation: Staff did not seek timely medical attention for the resident, it was alleged that on 09/01/23, resident R3 had an unwitnessed fall and sustained injuries. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported that R3 has a history of fall and R3s family member supplied the facility with a Life Station device that would alert 911 is R3 fell, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Staff present during the night shift did not report obtaining medical treatment for R3 after the 08/31/23 fall. Continued on 9099C.... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Administrator reported staff did not notify her of the 08/31/23 fall. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. Resident #3 was moved to healthcare facility and was not interviewed during the investigation due to R3’s cognitive impairment. The investigation revealed that on 08/31/23, R3 fell in the facility in early morning, staff placed R3 back in resident’s bed, did not make administrator aware of R3s fall, did not assess R3 for injury and did not obtain timely medical attention for R3 after the fall. R3 was sent out for medical treatment the next day, 09/01/23. Hospital staff observed R3 had multiple fractures; fracture to the left ribs, punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. Regarding the allegation: Staff did not follow the resident’s fall plan, it was alleged that on 09/01/23, in the early morning, resident R3 had an unwitnessed fall and sustained injuries. Interviews with Eight (8) out of (8) staff denied the allegation. Staff reported to being aware that R3 has a history of falls and staff were aware that R3 would get out of bed at night to urinate. R3s family member supplied the facility with a Life Station device that would alert 911 if R3 fell in the facility, however, staff could not recall if R3 was wearing the device during the 08/31/23 fall or when he was taken to the hospital on 09/01/23. Staff reported they were following the orders and instructions given by management staff. Interviews with three (3) out of three (3) residents could not corroborate the allegation and did not have any information to provide regarding the allegation. R3 is currently deceased and was not interviewed during the investigation due to R3’s cognitive impairment. Per the investigation, review of R3s records, it was observed that R3s Individual Service Plan dated 02/16/2023 noted that R3 was totally dependent, needed assistive devices; needed a walker and wheelchair, and shower chair. Section C page 9 of the R3’s assessment tool indicated that R3 requires assistance with ADLs due to weakness, fatigue, confusion and R3 is at risk for falls. Page 24 indicated the risks to R3s personal safety, as potential for falls, unsteady gait, and a fall history. R3’s resident appraisal dated 03/17/2023, indicated under services needed: R3 needs help getting up due R3’s balance and R3 being very wobbly. Bathing: R3 needs to be monitored so they do not fall. R3’s Functional Capability Assessment dated 03/17/2023 indicated R3’s balance is off. Additionally, on 06/03/2023, R3 had a fall in the facility patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off their bed and hit R3s head. On 08/31/2023 around 11:30PM , staff found R3 on the floor near R3s bed, and put R3 back into bed without assessing R3 for injury. Continued on 9099C......... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Staff did not inform the administrator of R3’s fall and staff did not seek immediate medical attention for R3 after the fall. The investigation revealed that staff did not follow R3s fall plan as R3 was admitted to the facility with a history of falls, required assistance to getting up due balance issues, and had two prior falls in the facility on 06/03/24 and 06/22/24. Staff did not render services needed for R3 as required per R3’s resident assessment/fall plan risk dated 02/16/23 that indicated the following: staff to assist R3 with ADL, staff to assist supervise/assist R3 with ambulation and transfer, staff monitor for R3 fall, the lack of care and supervision, resulted in R3 falling the facility on 08/31/24, which resulted in R3 sustaining injury that required medical treatment. Based on IBs and LPA's interviews conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. ***Immediate Civil Penalty in the amount of $500.00 is being issued today, due to staff neglect resulting in R3’s injury. Refer to LIC 421IM*** The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). If the department determines the injury of the resident is due to neglect. Exit interview was conducted with Laura Hernandez and a copy of this report, LIC 9099D, LIC 421 and appeal rights were provided.

On 08/20/2024. Licensing Program Analyst (LPA) S Vaid made an unannounced subsequent visit to the facility to conduct further investigations, in response to the above-mentioned allegations. LPA met with the staff Daisy Fitter and explained the purpose for the visit. Administrator Laura Hernandez joined shortly after. The investigation consisted of the following: Review of staff and resident rosters, tour of the physical plant with Administrator and viewed common areas and resident rooms. Obtained and reviewed the following documents for Residents# 3: Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA interviews with four (4) staff members and two (2) residents. Investigation Branch, Investigator Olivia Spindola conducted further investigation. Regarding the allegation: 1) Due to staff neglect, residents fell resulting in injury, 2) Staff did not seek timely medical attention for the resident and 3) Staff did not follow the resident’s fall plan. Four (4) out of four (4) staff denied the allegation and reported they were following the orders and instructions given by management staff. Two out of Two (2) residents could not corroborate the allegation and stated they were not aware of the incident happening at the facility. It is alleged that on 09/01/23, in the early morning, resident R3 had an unwitnessed fall and sustained injuries. Staff/Caregivers discovered R3 on the floor near the R3’s bed. Staff put R3 back in bed and staff did not notify the Facility Administrator of R3s fall. Staff did not assess R3 after the fall. According to staff statements (investigated by Spindola), the morning staff/caregiver mentioned R3 was feeling very sore and complained of pain. Staff/caregiver(s) did not perform a fall assessment to R3. After breakfast, upon rising from R3’s dining seat, R3 screamed in pain and staff sent R3 to Pomona Valley Hospital for emergency medical care. Investigator Olivia Spindola conducted further investigation. R3 was sustained multiple fractures; fracture to the left ribs, punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The Individual Service Plan dated 02/16/2023, received by Mountain View facility, noted that R3 was totally dependent, and required assistive devices for mobility; needs walker and wheelchair, shower chair. Section C page 9 of the assessment tool indicated R3 is at risk for falls. Section C page 24 identifies risks to personal safety; potential for falls, unsteady gait and fall history. R3’s resident appraisal dated 03/17/2023, indicated under services needed: balance is off, very wobbly. Bathing: needs to be monitored so they do not fall. R3’s Functional Capability Assessment dated 03/17/2023 indicated balance is off. On 06/03/23, R3 had a fall in the patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off R3s bed and hit their head. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 In the early morning hours of 09/01/2023, caregiver found R3 on the floor near R3s bed, and put R3 back into bed without assessing them. Overnight shift staff/caregivers did not inform the facility administrator of R3s fall and staff did not seek immediate medical attention for R3 after the 09/01/2023 fall. Staff neglected to render R3 assistance in meeting necessary medical assessment needed when fall occurs and pain is displayed, due to fall plan not being followed as shown in the documents reviewed. Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. ***An immediate Civil Penalty of $500.00 is being issued today, due to staff neglect resulting in injury. Refer to LIC 421IM*** The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f). If the department determines the injury of the resident is due to neglect. Exit interview was conducted with Laura Hernandez and a copy of this report, LIC 9099D, LIC 421 and appeal rights were provided.

Investigation consisted of the following: LPA requested a copy of staff and resident rosters, conducted a tour of physical plant and common areas. Requested and obtained the following documents for Residents# 3: Face sheet, Physician's Report, Needs and Services Plan, and Fall Prevention Plan. LPA conducted interviews with four (4) staff members and two (2) residents. LPA observed resident rooms to be free of hazards. Investigation Branch, Investigator Olivia Spindola conducted further investigation. Regarding the allegation: (1) Due to staff neglect, residents fell resulting in injury. (2) Staff did not seek timely medical attention for the resident. (3) Staff did not follow the resident’s fall plan. Four (4) out of four (4) staff denied the allegation. Two out of (2) residents could not corroborate the allegation. It is alleged that resident R3 had an unwitnessed fall and sustained injuries in the early hours of the morning, on 09/01/2023. Caregivers discovered R3 on the floor near the bed. Staff put R3 back in bed and did not notify the Facility Administrator, did not make assessment of the fall. According to staff statements (investigated by Spindola), morning caregiver mentioned R3 was feeling very sore and complained of pain. Caregiver(s) did not apply fall care assessment to resident. After breakfast, upon rising from dining seat R3 screamed in pain, was sent to Pomona Valley Hospital for emergency medical care. Investigator Olivia Spindola conducted further investigation. R3 was diagnosed at Pomona Valley Hospital with multiple fractured left ribs and punctured lung, a skin tear to left mid back, abrasions and bruising to left elbow, arm, and back area. The Individual Service Plan dated 02/16/2023, received by Mountain View facility, noted that R3 was totally dependent, need assistive devices; needs walker and wheelchair, shower chair. Section C page 9 of the assessment tool indicates resident is at risk for falls. Section C page 24 identifies risks to personal safety; potential for falls, unsteady gait and fall history. Residential appraisal dated 03/17/2023, indicates under services needed: balance is off, very wobbly. Bathing: needs to be monitored so they do not fall. Functional Capability Assessment dated 03/17/2023 indicates balance is off. 06/03/2023, R3 had a fall in the patio and was helped by staff. On 06/22/2023 R3 had an unwitnessed fall off their bed and hit their head. On the early morning hours of 09/01/2023, caregiver found R3 on the floor near their bed, and put R3 back into bed without assessing them. Overnight shift caregivers did not inform the facility administrator nor seeking medical attention and failed to render R3 services needed, due to fall plan not being followed as shown in the documents reviewed. Based on LPA's interviews and conducted of record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 ***An immediate Civil Penalty of $500.00 is being issued today, due to Resident # 3, (1) Due to staff neglect, residents fell resulting in injury. (2) Staff did not seek timely medical attention for the resident. (3) Staff did not follow the resident’s fall plan. Refer to LIC 421IM*** The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect. Exit interview was conducted with Laura Hernandez and a copy of this report, LIC 9099D, and appeal rights were provided.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by MedTech Leslie Pimiento. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. LPA Ramirez observed a tear in outdoor canopy. LPA Ramirez will issue Type B deficiency based on observation. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Planned Activities: LPA Ramirez observed staff leading cognitive memory games with residents during inspection. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 04/26/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. Residents with Special Needs : No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. LPA Ramirez observed sewing pins in room#16. LPA Ramirez will issue Technical Advisory based on observation. Auditory devices and delay egress perimeters were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cart and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. Staffing: Administrator Certificate for Laura Hernandez and it expires 08/25/2024. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for forty (40) non-ambulatory, of which ten (10) may be bedridden. This facility may retain no more than twenty (20) hospice residents. Resident Records/Incident Reports: LPA reviewed Resident files for six (6) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. One (1) deficiency was cited and two (2) technical advisories were issued. Exit interview conducted. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of citing deficiencies. LPA Maldonado met with Administrator, Laura Hernandez, and explained the purpose for the visit. During a complaint visit initiated on 12/04/23, LPA Maldonado conducted a tour of the physical plant with Staff, Daisy Fitter, and conducted a file review for Residents# 1-3 (R1-R3). During the inspection of the facility kitchen, LPA observed an insufficient amount of the required 2-day perishables, for the amount of residents currently in care- 39 residents. LPA observed (1) box of frozen hamburger patties, about (3) boxes of frozen breakfast waffles, (1) gallon of milk, (2) packages of frozen chicken, (2) frozen full size hams, (1) package of frozen ground beef, about (9) tubs of yogurt, about (11) bags of frozen sliced sandwich bread, about (50) fresh eggs, one tub of varied fresh vegetables were observed in the refrigerator, and one and a half bags of assorted vegetables in the freezer. No fresh fruits were observed. Per Laura, the facility should be receiving a food delivery later today or tomorrow. During the resident file review, LPA discovered that R2's file was missing an updated medical assessment (Physician's Report) as required annually for residents with dementia. The current Physician's Report is dated 11/18/22. Per California Code of Regulations, Title 22, deficiencies were observed and cited on the LIC809-D. An exit interview was conducted with Administrator, Laura Hernandez, and a copy of this report and appeal rights were provided.

Licensing Program Analysts (LPAs) Elizabeth Irra and Kimberly Ramirez conducted the required annual inspection. LPA met with Laura Hernandez (Administrator) and discussed the purpose of today’s visit. This facility is licensed to serve (40) non-ambulatory residents, of which, (10) may be bedridden and (20) may be on hospice. Per Administrator, there are (2) bedridden residents and there are (7) residents under hospice care at this time. This facility consists of (2) single story buildings. The front building consists of a reception area, administrative offices, employees lounge, conference room, and commercial-size kitchen. The back building includes a medication room, resident rooms, living room, dining room, bathrooms, and indoor/outdoor areas. Residents bedrooms have the required furniture. Most of the resident bedrooms have a “jack and jill” bathroom. Bathrooms were clean and operational. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (40) non-ambulatory residents, of which, (10) may be bedridden and (20) may be on hospice. Staff were unable to provide proof of liability insurance coverage (citation issued). Physical Plant & Environment Safety: LPAs toured facility grounds. Smoke alarms and carbon monoxide detectors were observed (both tested and operable). Fire extinguishers are located throughout the premises (service date of 02/01/23). Signal system was tested and operable. The water temperature measured as follows: 106.3* in the bathroom between room #2 and room #3, 106.5* in the bathroom between room #4 and room #5, 112.0” in bathrooms between rooms #12, #13, #14 and #15. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Bathrooms had non-skid surfaces and grab bars. **Refer to LIC 9099C for the continuation of this report.** 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Physical Plant & Environment Safety (cont). During facility tour, LPAs observed debris on the side of the back building that are accessible to residents, visitors and staff (citation issued). 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). Staffing : There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training : Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator/S-1 through Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training. Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #5 (R-5). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, Appraisal/Needs and Services Plan, Resident Rights were observed. Resident Rights-Information: Resident rights are posted and included in Resident files. Planned Activities: Activity schedule is posted. There is an activity director for this facility. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items.. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining area has adequate seating. Posted menu observed. Refer to LIC 9099C for continuation of this report. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and//or original containers. The facility uses the Medication Administration Record (MAR) to document medications given. Medications are administered as prescribed by the Physician. The facility provides incidental medical services. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Deficiencies cited. Refer to LIC 9099D. Exit interview conducted, copy of appeal rights and a copy of this report was provided to Laura Hernandez