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 regarding the alleged allegation Resident #1 informed LPA that when resident requested for more medication staff declined. Unsubstantiated LPA informed Resident #1 that staff must follow medication orders as specified on medication labels and staff cannot exceed medication dosage. Second allegation: Staff did not ensure resident was treated with dignity and respect. Regarding the allegation stated above, LPA conducted an interview with Resident #1 regarding the alleged allegation Resident #1 informed LPA that staff is ignoring residents’ pain and staff are not giving resident more pain medication when requested. Resident #1 informed LPA that the resident has no issues with the facility but does not like the fact that facility staff does not give the resident more medication. LPA conducted an interview with Staff #1 regarding the alleged allegation Staff #1 informed LPA that there have not been any witnesses or reports stating that Staff #2 has left resident’s bedroom door open when cold. LPA conducted an interview with Resident #2 regarding the alleged allegation and Resident #2 informed LPA that resident have not witnessed Staff #1 mistreat or disrespect Resident #1. Third allegation: Staff are not providing adequate food service. Regarding the allegation stated above, LPA conducted an interview with Resident #1 regarding the alleged allegation Resident #1 informed LPA that there are days that the food that is being served is not good. Resident #1 stated that Staff #3 does provide resident with alternatives however, resident does not like the alternatives given. LPA conducted a food supply inspection and during the inspection LPA observed three refrigerators with enough food supply to meet the current needs of the residents. LPA conducted an interview with Staff #3 regarding the alleged allegation and Staff #3 informed LPA that alternative meals are offered to Resident #1. LPA conducted an interview with Resident #2 regarding the alleged allegation and Resident #2 informed LPA that the facility provides residents with three meals a day and offers alternative meals to residents. LPA conducted an interview with Resident #3 regarding the alleged allegation and Resident #3 informed LPA that the facility provides three meals to residents in addition, Resident #3 informed LPA that the facility also provides seconds when requested as well as other alternative options. Based on corroborating evidence LPA has determined that the above allegation is Unsubstantiated, meaning that 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Steven Prado.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 56-AS-20260415124350

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Steven Prado and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (24) current census (22). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected residents’ bedrooms; they are equipped with required furniture such as mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 113.5 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside staff office inaccessible to residents in care. Overall, the facility, in good repair, and operates in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. LPA observed Liability insurance to be current with a renewal date of 4/30/26. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator.the state’s words, verbatim · CDSS document, Apr 7, 2026

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 food supply twice a week every Wednesday. Unsubstantiated LPA conducted an interview with Resident #1, Resident #2, and Resident #3, LPA went over the allegation with R#1-3 and all stated that they have no issues or concerns regarding food or the food supply at the facility and that the facility provides them with three meals a day (breakfast, lunch, and dinner). Furthermore, R#1-3 also informed LPA that facility provides snacks. Second allegation: Licensee did not ensure that facility bathrooms were maintained in good repair. Regarding the allegation LPA conducted a bathroom inspection during inspection LPA observed two bathrooms to be in standard and in good repair inside building #1. In addition, LPA conducted a bathroom inspection inside building #2, LPA observed 2.5 to be in standard and in good repair. LPA conducted an interview with Staff #1 who informed LPA that all bathrooms were recently remodeled six-months ago. In addition, LPA was able to inspect a total of 4.5 restrooms between building #1 and building #2 during the inspection LPA did not observe mold, broken tiles, or restrooms to be in despair. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated: meaning that 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Stephen Prado at the end of the visit.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 56-AS-20250915081059

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Becky Mann and Lavette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Steven Prado, Administrator. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (24) current census (21). LPAs was accompanied by Administrator Steven, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). LPAs conducted a walk through of the facility. LPA observed and tested the hot water temperature for four (4) restrooms. Two (2) of the four (4) restroom water tested at 91.5 and 103.1 which is below regulations. The other two restrooms tested at 128.5 and 130.1 which is above regulations. Deficiency cited. LPAs observed several residents emergency exit doors from their bedroom leading to the outside to be damaged and unsafe due to water damage. The paint on the door is chipped and peeling. Deficiency cited. LPAs inspected resident’s bedrooms; they are equipped with required furniture such as: beds, mattresses, and storage space. LPA observed all residents rooms were missing either a lamp, chair or night stand. Technical violation issued. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. During walk through LPAs observed that chemicals, toxins and sharps were inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside staff office inaccessible to residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPAs reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. Resident #1 (R1) does not have Physician Report on file. Deficiency cited. LPAs reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Based on LPAs observations and record reviews, four (4) out of four (4) staff is not CPR certified. Deficiency cited. Medications were audited at random. Licensee did not have Medication Administration Record (MAR) for Resident #2 (R2) on file. Deficiency cited. LPAs requested to review the facilities Infection Control Plan and the Administrator was unable to locate the file for review. A technical violation issued. Licensee does not have an earthquake/fire drill on file. Technical violation issued. Based on the observations made during today’s visit, deficiencies and technical violations were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report LIC809, LIC809C, LIC809D, LIC9102, along with appeal rights were provided to Administrator Steven at the end of the visit.the state’s words, verbatim · CDSS document, Jun 3, 2025

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

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. Substantiated Based on the evidence gathered during investigation, the above allegation is Substantiated. Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Maintenance and Operation 87303 (a), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. Second Allegation: Facility is unsanitary. Six(6) out of Six(6) Residents stated housekeeping visits facility once a week and bathrooms are in unsanitary condition. Bedrooms were not clean, moldy and smells of odor present in the bedroom. Pile of unwashed laundry observed by the LPA outside Building#1 back door. Outdoor area was cluttered with gardening tools. Based on the evidence gathered during investigation, the above allegation is Substantiated. Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Maintenance and Operation 87303 (a), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. An exit interview was conducted where this report LIC 9099, LIC9099 C and LIC 9099D and Appeal Rights were discussed, and a copy was provided to Facility House manager Rosy Riverra.the state’s words, verbatim · CDSS document, May 12, 2025 · control 56-AS-20250505153330

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(1)(f) · Plan of correction due date: May 13, 2025

Maintenance and Operation: (1)(f) The facility shall be clean, safe, sanitary and in good repair and free of leaks at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observations, the licensee failed to esnsure that the facilty is kept clean and sanitary all all times for residents, which can poses a Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: Facility Administrator/Licensee will have professionallly clean Floor surfaces in bath, restrooms and other areas in sanitary and odorless condition and email training of the staff to LPA Singh by the POC due date 5/13/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 13, 2025

Maintenance and Operation: (a)(f) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observations, the licensee failed to esnsure that the facilty is in good repair at all times, which can poses a Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: Facility Administrator/Licensee will have all repair done-doors,blinds fixed and email invoice to LPA Singh by the POC due date 05/19/2025.

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. Substantiated Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Maintenance and Operation 87303 (a), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights. to Facility Caregiver Rosy Rivera at the end of the visit. Unsubstantiated; meaning that 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Rosy Rivera at the end of the visit.the state’s words, verbatim · CDSS document, Mar 18, 2024 · control 56-AS-20240314125534

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Mar 19, 2024

Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observations, the licensee failed to esnsure that the facilty is keept clean and sanitary all all times for residents, which can poses a Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2024

Plan of correction: Facility Administrator/Licensee will have a professional exterminator come to the facility and address the infestation of bed bugs. Facility will no longer utilize spraying method as the facility has been having a continuous problem with bed bugs and has yet to be resolved. Licensee/Administrator will look into a second treatment method completed by licensed exterminator to treat bed bugs and will email Proof of invoice to LPA Guerrero by POC date 3/19/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst's (LPAs) Paola Guerrero and Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Caregiver Rosy Rivera and was granted entry to the facility. At the time of the visit there was four (4) staff present, and thirteen (14) residents present and eight (8) residents were out in the community. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (24) current census (23). LPA was accompanied by Facility Administrator Joney and Caregiver Rosy, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). While conducting a walk through of the facility LPAs observed facility vent to be covered with accumulating dust. LPAs also observed two resident bathrooms to have broken tiles. In addition, LPAs observed black build-up on bathroom tile and ceiling. Water temperature in building #1 measured at 130.9 exceeding regulation requirements. LPAs observed that facility did not have skid mats in restrooms. During walk through LPAs observed that facility has two separte buildings with no signal systems facility has a census of 23 residents. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. During walk through LPAs observed Cleaning supplies such as bleach to be accessible to residents, LPAs had caregiver secure bleach by locking laundry room door. There was a designated storage space for resident/staff files. Medications are kept inside staff office inaccessible to residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. While completing food inspection LPAs observed expired canned jalapenos along with diced green chili cans. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPAs reviewed five(5) resident files for admission agreements, updated physician reports, and needs and services plans. LPAs also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, eight (8) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809),(809D), along with appeal rights were provided to Facility Caregiver Rosy Rivera at the end of the visit.the state’s words, verbatim · CDSS document, Mar 8, 2024

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 residents. The Department was not able to interview Resident 1 (R1). Based on the information obtained during the investigation, the allegations are therefore UNSUBSTANTIATED. A finding of unsubstantiated means that, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was reviewed with and a copy was provided to Joney Carlos. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 20, 2023 · control 18-AS-20210601154523

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

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 public transportation to get around the community or they contact transportation service provider. Allegation 3: Facility changed resident's choice of physician(s). Staff interviews reveal that the facility does not have their own physician however, residents who are receiving home health services are visited in the facility by medical provider. Interviews with residents confirm that they have their own physicians. Unsubstantiated Allegation 4: Facility had pests. Records revealed that the Department has been made aware that the facility has re-occurring issues with pests. Additional records reviewed confirmed the facility is receiving ongoing, scheduled pest control service. Based on the information obtained during the investigation, the allegations are therefore UNSUBSTANTIATED. A finding of unsubstantiated means that, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was reviewed with and a copy was provided to Joney Carlos.the 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 the alleged violations did or did not occur. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 20, 2023 · control 18-AS-20210615162542

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.