197608323-7-20-2024-28-AS-BPEA-D7CRAA-20240720125050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608323
Report Date: 07/20/2024
Date Signed: 07/20/2024 12:51:08 PM

Document Has Been Signed on 07/20/2024 12:51 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, LLC		FACILITY NUMBER:	197608323
ADMINISTRATOR:	LINDA MCINTOSH		FACILITY TYPE:	740
ADDRESS:	603 TOCINO DRIVE		TELEPHONE:	(626) 205-3211
CITY:	DUARTE	STATE: CA	ZIP CODE:	91010
CAPACITY:	6	CENSUS: 6	DATE:	07/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Linda McIntosh - Administrator Britteny McIntosh - House Manager		TIME COMPLETED:	01:00 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) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Chile Shikabenga, Care Staff and Lolley Seckel, Care Staff and explained the purpose of the visit. At approximately 10am, Administrator Linda McIntosh and House Manager, Britteny McIntosh arrived and assisted LPA with the inspection. The facility is licensed to care for six (6) elderly residents ages 60 and above, approved for (6) non-ambulatory residents and hospice waiver for (5) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Bathroom has hygiene items such as hand soap and toilet paper. Paper towels are only provided in the bathroom. Facility uses cloth/reusable towels in the kitchen. Administrator stated that she will supply paper towels in the kitchen moving forward. Operational Requirements: The Infection Control and Dementia plan have been added to the Infection Control Plan. A fire clearance is in place. Last Fire Drill was conducted on 06/23/2024 and training conducted on a monthly basis. Liability Insurance policy is valid and expires on 12/20/2024. Administrator will send a detailed summary of the liability insurance to LPA. Facility does not handle cash resources for the residents. Facility has working signal systems in exit points, which LPA along with the Administrator tested during the visit. Physical Plant/Environment Safety: The facility is a 2-story home located in a residential neighborhood, 1st floor consists of (4) resident bedrooms, (2) bathrooms, living room with screened fireplace, den/tv area with screened fireplace, kitchen, dining area, laundry area, detached garage, backyard with gated swimming pool, small storage building, shed, shaded patio area. 2nd floor consists of office area, staff sleeping quarter with curtains as a divider for privacy and (1) bathroom. Currently, there are six (6) clients living in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, bed with 1/2 and full bed rails, linen, dresser, light, chair and sufficient closet space. Exit doors are free of any obstruction and there is a gated swimming pool in the backyard. Backyard was inspected and has a shaded area and sitting area. Laundry area is in the hallway. There are cameras without audio in the front/back yards and common areas inside the home. There is (1) fire extinguisher in the kitchen which was just serviced in July 2024. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. At 9:50am, readings were 105.3 deg in bathroom #1 (upstairs), 116.6 deg F in bathroom #2 and 113.5 deg F in bathroom #3. ***REPORT CONTINUED ON LIC809-C***

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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, LLC	FACILITY NUMBER: 197608323
	VISIT DATE: 07/20/2024

NARRATIVE

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Staffing: A total of seven (7) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 07/27/2025.
Resident Rights-Information: Client personal rights are posted. Facility provides internet services to all residents and have access to the facility phone.
Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Activities supply observed
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Resident Records-Incident Reports: LPA reviewed (5) resident files. Resident files are maintained at the facility. Admission Agreement, I.D. and Emergency Information (Face sheet), Physician's Report (including TB and Ambulatory Status), Physician's order for bed rails, Consent For Medical Treatment, Appraisal and Needs Services plan, Resident Personal Rights, and Resident Personal Property observed.
Health Related Services: Medications were reviewed for (5) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed and stored in a locked medicine cart.
Incidental Medical Services: There is one (1) resident with a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

No deficiency cited. Exit interview and a copy of this report was provided to the Administrator, Linda McIntosh.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette Pena	TELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2024

LIC809 (FAS) - (06/04)

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