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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 02/01/2023
Date Signed: 02/01/2023 04:23:21 PM

Document Has Been Signed on 02/01/2023 04:23 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 CENTERFACILITY NUMBER:
197801605
ADMINISTRATOR:LAURA HERNANDEZFACILITY TYPE:
740
ADDRESS:715 WEST BASELINE ROADTELEPHONE:
(909) 626-6633
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 40CENSUS: 32DATE:
02/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Laura HernandezTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an investigation visit regarding complaint received 1/26/2023 to the facility. During the investigation visit, LPA reviewed Resident 1's (R1) facility file and observed the following :
  • R1 did not have a reappraisal updating declining mental/ health issues while in the facility.
  • Statements from administrator revealed that R1 had not been reassessed although staff observe decline in mental/ health conditions.
  • Administrator stated that R1 continously refused all attempts to reassess.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the deficiencies observed were documented on the LIC-809D.

Exit interview held/copy of report provided along with appeal form to Facility Staff Elvira Cortez.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2023
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
Document Has Been Signed on 02/01/2023 04:23 PM - It Cannot Be Edited


Created By: Alma Gonzalez On 02/01/2023 at 03:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
87463(a)

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87463 Reappraisals
The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition...

This requirement is not met as evidenced by:
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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LPA observed that R1 did not have a reappraisal to update her declining mental/ health issues, which poses a potential Health, Safety or Personal Rights risk to the residents in care.
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Type B
02/10/2023
Section Cited
HSC87466

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87466 Observation of Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals un met needs.

This requirement is not met as evidenced by:
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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Based on interviews with staff which indicated that staff noticed a change in R1 after time of admission but did not conduct a reassessment due to R1 continous refusal, which poses a potential Health, Safety or Personal Rights risk to the residents in care.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2