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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608323
Report Date: 02/06/2023
Date Signed: 02/06/2023 12:39:00 PM

Document Has Been Signed on 02/06/2023 12:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOUNTAIN VIEW TERRACE, LLCFACILITY NUMBER:
197608323
ADMINISTRATOR:LINDA MCINTOSHFACILITY TYPE:
740
ADDRESS:603 TOCINO DRIVETELEPHONE:
(626) 205-3211
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 6CENSUS: 5DATE:
02/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Anna Phiri, StaffTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus on the Infection Control Domain. LPA arrived unannounced and met with Staff, Anna Phiri, who allowed entry. Administrator, Linda McIntosh, arrived at approximately 11:00 am to assist with the visit. The facility is licensed to serve residents ages 60 and above. The fire clearance is approved for 6 non-ambulatory residents and the facility has a hospice waiver approved for 5 residents.

The facility consists of 4 resident bedrooms, 2 bathrooms, living room, dining room, kitchen, family room, and an attached garage. The upstairs is utilized as the Administrator's office and living space for live-in staff. The swimming pool in the backyard is surrounded by a gate. The facility submitted a mitigation plan in which they are still following.

The inspection consisted of the following:
  • Screening and temperature logs were observed for both visitors and staff. COVID-19 signage were posted at the front entrance and throughout the home. There were sufficient food supplies of 2-day perishable and a week of non-perishable observed. Each resident bedroom had the required furniture and is well maintained. PPE supplies for at least 30-days are in storage at the home. Sharps, knives, and cleaning solutions were locked in the cabinet under the stove. Medications were locked and centrally stored. LPA reviewed the medications for all 5 residents and there were no discrepancies found. Fire extinguishers were observed to be fully charged and last inspected on 5/12/2022. The smoke and carbon monoxide combo detectors are operational. LPA observed all staff and visitors wearing a face covering during the visit today. The resident files have updated contact information. Per the Administrator, they are able to obtain additional staffing if needed.

LPA did not observe any deficiencies today. An exit interview was conducted and a copy of this report was given to Administrator McIntosh.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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