Mountain View Residential Care

Allegation investigated: Staff mishandle residents medication Staff did not ensure resident was treated with dignity and respect Staff are not providing adequate food service

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Steven Prado and explained the purpose of the visit regarding the allegations stated above. First allegation: Staff mishandle residents’ medication. Regarding the allegation stated above, LPA conducted an interview with Staff #1 regarding the alleged allegation Staff #1 denied the allegation and informed LPA that medication for Resident #1 was not denied however, Staff #1 indicated that the medication dosage was not administered to Resident #1 because Resident #1 was requesting medication exceeding R#1 prescribed dosage. Upon medication review LPA observed that medication label indicated 1 tablet by mouth every 8 hours Staff #1 further reported that Resident #1 was requesting to be given two tables for pain and staff provided Resident #1 with one tablet as it indicates on Resident #1 medication label. LPA conducted an interview with Resident #1 rthe state’s words, verbatim · CDSS document, Apr 17, 2026 · control 56-AS-20260415124350

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee did not ensure that an adequate supply of food was maintained on the premises. Licensee did not ensure that facility bathrooms were maintained in good repair.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Stephen Prado and explained the purpose of the visit. The investigation consisted of interviews and observations. First allegation: Licensee did not ensure that an adequate supply of food was maintained on the premises. Regarding the allegation LPA conducted an inspection of facilities food supply during the inspection LPA observed enough food supply stored inside three (3) refrigerators and inside freezers. LPA observed enough food supply to be stored to meet the needs of residents in care. During the inspection LPA observed food to be fresh, safe, and shelf stable. In addition, LPA observed that facility’s refrigerators and freezers are in standard with their temperatures according to Tile22 regulation. LPA conducted an interview with S#1 regarding the allegation stated above S#1 informed LPA that facility restocks on fthe state’s words, verbatim · CDSS document, Sep 16, 2025 · control 56-AS-20250915081059

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility is in disrepair. Facility is unsanitary.

On 05/12/2025 Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility to deliver findings for the allegations stated above. LPA met with Facility Staff-Rosy Rivera and explained the reason for the visit. During today’s visit, LPA Singh conducted interviews with residents, conducted interviews with staff, and requested documents. First Allegation: Facility is in disrepair During visit LPA conducted a room inspection and the following observations were made. Building #1 (B1) and Building#2 (B2) were in disrepair. LPA Singh toured the facility and bathrooms were in disrepair observed leaking faucet in front house (right side bathroom facing down hallway) and bathroom in disrepair in the second (back) house still not fixed.LPA Singh observed broken doors and broken window screens of building#2. No repair records available pertinent to this allegation. Substantiatedthe state’s words, verbatim · CDSS document, May 12, 2025 · control 56-AS-20250505153330

Allegation investigated: Facility has bed bugs

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Caregiver Rosy Rivera and explained the purpose of the visit. The investigation consisted of observation and interviews. Allegation: Facility has bed bugs During visit LPA conducted a room inspection and the following observations were made. Building #1 (B1) Room#1-4, bed bugs were observed on mattresses and on sheet protectors. Building #2 (B#2) Room#5-9, bed bugs were observed on mattresses and on sheet protectors. Resident #2 (R#2) reported to LPA of being bit by bed bugs all night. S#1 stated facility sprays to mitigate the spread of bed bugs, however, the problem is continuous and bed bug issue has not been resolved. Based on the evidence gathered during investigation, the above allegation is Substantiated. Substantiatedthe state’s words, verbatim · CDSS document, Mar 18, 2024 · control 56-AS-20240314125534

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility not providing adequate cleaning services to resident rooms. Staff yell at residents.

Licensing Program Analysts (LPA) Anna Bueno, Magda Malcore, and Bianca Wolcott conducted a subsequent unannounced visit to the facility to continue the investigation the above mentioned complaint allegations and deliver findings. LPAs identified themselves to staff who was informed of the reason for today’s visit and contacted licensee Nenita Carlos. The Department investigation included staff and resident interviews and facility inspections. Allegation 1: Facility not providing adequate cleaning services to resident rooms. Staff interviews reveal that resident rooms are cleaned as needed or requested by residents and are also cleaned on a weekly schedule. During unannounced LPA inspection of resident bedrooms, LPAs observed that rooms are kept tidy according to resident preference and LPAs observed facility staff cleaning rooms. Allegation 2: Staff yell at residents. Interviews with residents reveal that staff do not yell at residents and staff interviews deny that they yell at residethe state’s words, verbatim · CDSS document, Oct 20, 2023 · control 18-AS-20210601154523

Allegation investigated: Facility did not follow resident's care plan. Facility did not transport resident to medical appointments. Facility changed resident's choice of physician(s). Facility had pests.

Licensing Program Analysts (LPA) Anna Bueno, Magda Malcore, and Bianca Wolcott conducted a subsequent unannounced visit to the facility to continue the investigation the above mentioned complaint allegations and deliver findings. LPAs identified themselves to facility staff who was informed of the reason for today’s visit and contacted licensee Nenita Carlos. The Department investigation included staff and resident interviews and facility inspections. Allegation 1: Facility did not follow resident's care plan. Interviews with resident revealed that, while they go to their own medical appointments, residents will provide copies of the summary visit to staff. Staff interviews reveal that home health service providers communicate with staff on changes to their care. Allegation 2: Facility did not transport resident to medical appointments. Records reviewed show that some residents services that include transportation services. Interviews with residents revealed that they are able to use pthe state’s words, verbatim · CDSS document, Oct 20, 2023 · control 18-AS-20210505121329

Allegation investigated: Residents are using illegal drugs at the facility.

Licensing Program Analysts (LPA) Anna Bueno, Magda Malcore, and Bianca Wolcott conducted a subsequent unannounced visit to the facility to continue the investigation the above mentioned complaint allegations and deliver findings. LPAs identified themselves to facility staff who was informed of the reason for today’s visit and contacted licensee Nenita Carlos. The Department investigation included staff and resident interviews and facility inspections. The investigation revealed that Resident 1 (R1) is not a resident of this facility but lives in the Independent Room & Board located next door to the facility. LPAs were unable to speak with Witness 1 or R1. Staff and resident interview deny consuming illegal substances at the facility. Based on the information revealed during the investigation, this allegation is UNSUBSTANTIATED at this time. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove ththe state’s words, verbatim · CDSS document, Oct 20, 2023 · control 18-AS-20210615162542

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff is financially abusing resident.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Caregiver Rosy Rivera and explained the purpose of the visit. The investigation consisted of interviews and a review of records. First allegation, Staff is financially abusing resident. LPA conducted a review of records and observed that on 5/23 facility had evicted Resident #1 (R1). On 6/5 LPA observed that facility cashed Resident # 1 (R1) rent along with PNI. LPA also observed that on 7/6 facility attempted to cash checks for the month of July however, checks were returned because of VOID. The facility was informed that $1,311.12 for rent and $52.00 for PNI is owed and must be paid back to ROG Services. Based on the evidence gathered during the investigation, the above allegation is Substantiated. Substantiatedthe state’s words, verbatim · CDSS document, Sep 1, 2023 · control 56-AS-20230816105227

Allegation investigated: Facility staff does not ensure hallways used by residents are clear from tripping hazards

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Manager Joney Carlos and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Facility staff does not ensure hallways used by residents are clear from tripping hazards. LPA, Fire Marshal, along with Assistant Building Official (ABO), conducted a walkthrough of the facility and observed extension cords running from the facility laundry room over to Building #2, LPA oserved commercial power outlet connected to several appliance outlets in Building #2 which can be a potential fire/and tripping hazard for residents in Building #2; Throughout the walkthrough LPA observed ten (10) power outlets being utilized all throughout building #2. LPA asked Staff #1 about the issue regarding the power outlets around the facility S#1 stated that facility is working on getting their electrithe state’s words, verbatim · CDSS document, Aug 24, 2023 · control 56-AS-20230711142641