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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608323
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:37:10 PM


Document Has Been Signed on 10/05/2023 03:37 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
CCLD Regional Office, 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: 6DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Linda McIntosh, administratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with administrator, Linda McIntosh, who assisted with the visit. The facility is licensed to serve six (6) non-ambulatory residents who are ages 60 and above and approved for five (5) Hospice Waiver. LPA discussed the purpose of today's visit with administrator.

During the visit, LPA conducted staff/resident interviews, used CARE inspection tool, toured the facility, reviewed food supply, reviewed medications, and reviewed staff/residents records.

The facility is a single story home located in a residential neighborhood, consisted of four (4) resident bedrooms, two (2) bathrooms, living room, dining room, kitchen, family room, and an attached garage. Administrator's office and living space for live-in staff is located upstairs. The swimming pool in the backyard is surrounded by a gate. Medications were centrally stored, locked and inaccessible to residents in care. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Hot water temperature measured at 116.5 degrees Fahrenheit. Sufficient of linen supplies and personal hygiene supplies were observed. Sufficient supply of perishable and non-perishable foods was observed. All exit doors are equipped with auditory device alarms. Last fire drill was conducted on 10/2/23. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged. All mandated documents and signages are posted in common areas.

No deficiency was cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to administrator, Linda.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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