197801605-9-5-2023-28-AS-EIRA-CV9S2D-20230901132923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 09/01/2023
Date Signed: 09/05/2023 07:56:00 AM

Document Has Been Signed on 09/05/2023 07:56 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MOUNTAIN VIEW CENTER		FACILITY NUMBER:	197801605
ADMINISTRATOR:	LAURA HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	715 WEST BASELINE ROAD		TELEPHONE:	(909) 626-6633
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	40	CENSUS: 38	DATE:	09/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Laura Herandez		TIME COMPLETED:	01:45 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 Analysts (LPAs) Elizabeth Irra and Kimberly Ramirez conducted the required annual inspection. LPA met with Laura Hernandez (Administrator) and discussed the purpose of today’s visit. This facility is licensed to serve (40) non-ambulatory residents, of which, (10) may be bedridden and (20) may be on hospice. Per Administrator, there are (2) bedridden residents and there are (7) residents under hospice care at this time. This facility consists of (2) single story buildings. The front building consists of a reception area, administrative offices, employees lounge, conference room, and commercial-size kitchen. The back building includes a medication room, resident rooms, living room, dining room, bathrooms, and indoor/outdoor areas. Residents bedrooms have the required furniture. Most of the resident bedrooms have a “jack and jill” bathroom. Bathrooms were clean and operational. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for (40) non-ambulatory residents, of which, (10) may be bedridden and (20) may be on hospice. Staff were unable to provide proof of liability insurance coverage (citation issued). Physical Plant & Environment Safety: LPAs toured facility grounds. Smoke alarms and carbon monoxide detectors were observed (both tested and operable). Fire extinguishers are located throughout the premises (service date of 02/01/23). Signal system was tested and operable. The water temperature measured as follows: 106.3* in the bathroom between room #2 and room #3, 106.5* in the bathroom between room #4 and room #5, 112.0” in bathrooms between rooms #12, #13, #14 and #15. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Bathrooms had non-skid surfaces and grab bars. Refer to LIC 9099C for the continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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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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 CENTER	FACILITY NUMBER: 197801605
	VISIT DATE: 09/01/2023

NARRATIVE

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Physical Plant & Environment Safety (cont). During facility tour, LPAs observed debris on the side of the back building that are accessible to residents, visitors and staff (citation issued). The following items were observed: (1) unsecured tall ladder, (2) large air conditioning units, (6) metal-like framing items, a shed inside the packaging, (1) roll of insulation, (1) plywood, (1) wooden pallet, (2) trays, (1) Geri Chair and (6) wheelchairs (of which 1 appears to be disassembled).

Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator/S-1 through Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training.

Resident Records-Incident Reports: LPA reviewed Resident files for Resident #1 (R-1) through Resident #5 (R-5). Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Functional Capabilities, Appraisal/Needs and Services Plan, Resident Rights were observed.

Resident Rights-Information: Resident rights are posted and included in Resident files.

Planned Activities: Activity schedule is posted. There is an activity director for this facility.

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of 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. Dining area has adequate seating. Posted menu observed.

Refer to LIC 9099C for continuation of this report.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

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 CENTER	FACILITY NUMBER: 197801605
	VISIT DATE: 09/01/2023

NARRATIVE

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Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and//or original containers. The facility uses the Medication Administration Record (MAR) to document medications given. Medications are administered as prescribed by the Physician. The facility provides incidental medical services.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place.

Deficiencies cited. Refer to LIC 9099D.

Exit interview conducted, copy of appeal rights and a copy of this report was provided to Laura Hernandez

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/05/2023 07:56 AM - It Cannot Be Edited

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 CENTER	FACILITY NUMBER: 197801605
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on facility administrator interview, the licensee did not comply with the section cited above, (38) out of (38) residents which poses an immediate health, safety or personal rights risk to persons in care. During today's visit, staff were unable to provide proof of liability insurance coverage
	POC Due Date: 09/02/2023
	Plan of Correction
1 2 3 4	Facility administrator to submit proof of liability insuranced with the limits noted above to LPA Irra by POC due date.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, (38) out of (38) residents which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed debris on the side of the back building that are accessible to residents, visitors and staff. The following items were observed: (1) unsecured tall ladder, (2) large air conditioning units, (6) metal-like framing items, a shed inside the packaging, (1) roll of insulation, (1) plywood, (1) wooden pallet, (2) trays, (1) Geri Chair and (6) wheelchairs (of which 1 appears to be disassembled).
	POC Due Date: 09/02/2023
	Plan of Correction
1 2 3 4	Facility Administrator to remove the debris and provide proof of correction (photos) to LPA Irra by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023

LIC809 (FAS) - (06/04)

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