<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850205
Report Date: 12/01/2022
Date Signed: 12/02/2022 08:20:57 AM

Document Has Been Signed on 12/02/2022 08:20 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MONTARE VISTAFACILITY NUMBER:
195850205
ADMINISTRATOR:MODRESKY, MICHEALFACILITY TYPE:
772
ADDRESS:14339 VALLEY VISTA BLVDTELEPHONE:
(917) 374-4215
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY: 6CENSUS: 4DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Paige PorterTIME COMPLETED:
03:58 PM
NARRATIVE
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
Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required
annual visit at 2:00 p.m. This annual had an emphasis on infection control practices and procedures. LPA Urena met with Paige Porter, Program Director (PD), and explained the reason for the visit.

The LPA, and the PD toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked and inaccessible in the pantry room. A seven day supply of non- perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean, and all appeared functional. There is an adequate supply of emergency food. Kitchen, laundry, and house cleaning supplies are stored, locked, and located in the laundry room.

BEDROOMS: There are three bedrooms for resident use, double occupancy. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing, and personal belongings.

BATHROOMS: The bathrooms are fully stocked with paper towels, hand soap, and hand washing signs. The showers have non-skid mats.

Continues on LIC809 C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MONTARE VISTA
FACILITY NUMBER: 195850205
VISIT DATE: 12/01/2022
NARRATIVE
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
COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There are televisions, and entertainment equipment in the group rooms, and outdoor area.


OUTDOOR AREA: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard area of the facility, and is furnished with outdoor furniture for residents’ use. The building has a central entrance for residents and visitors. Fire emergency gates are clear of obstructions. A fenced, and locked swimming pool is found in the back of the house.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee Representative regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA explained the importance of wearing masks/PPE by staff, residents and visitors.


Exit interview was conducted and reviewed with Montage Recovery CA LLC representative, Paige Porter. A copy of the report was provided via email.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2