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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 05/16/2023
Date Signed: 05/16/2023 01:56:13 PM

Document Has Been Signed on 05/16/2023 01:56 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: 35DATE:
05/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Elvira Cortez, Activity DirectorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan initiated a case management visit to issue deficiencies observed during a complaint investigation #28-AS-20230512120959. LPA met with Staff, Elvira Cortez, and explained the purpose.

During the tour on 5/16/23, LPA observed strawberry yogurt bars in a tray uncovered and a gallon of juice without the top left inside the refrigerator, located in the second building dining room. In addition, the signal system in the residents' rooms are not operable. Staff stated a new signal system was purchased and is waiting on installation. LPA observed the shipment of the signal system was dated 1/20/23 and the box of call systems are left in the owner's office. Staff stated that they are consistently conducting round checks every 2 hours and residents are given a bell to signal staff in the meantime.

The deficiencies are issued on the LIC809D form. A civil penalty for a repeated violation is also issued. The report along with appeal rights were given to staff Cortez.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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 05/16/2023 01:56 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 05/16/2023 at 01:29 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: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2023
Section Cited
CCR
87555(b)(28)

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87555 General Food Service Requirements:
(b) The following food service requirements shall apply:
(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.
This requirement is not met as evidenced by:
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The licensee shall ensure all foods are protected against contamination. An in-service training shall be conducted with all staff and log shall be submitted to LPA by 5/23/23.
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Based on LPA observation, food items were not properly covered which poses an potential health and safety risk to residents in care.
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Type B
05/23/2023
Section Cited
CCR87303(i)(1)(B)

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87303 Maintenance and Operation (i) Facilities shall have signal systems... (1)All facilities licensed for 16 or more and all residential facilities having separate floors...shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location...
This requirement is not met as evidenced by:
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The licensee shall ensure the signal system is operable. The written plan shall indicate how the deficiency will be corrected and estimated date in which the signal system will be installed. This plan is due by 5/23/23.

**A civil penalty is being assessed for a repeated violation.
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Based on observation and interview, the facility did not have a working signal system for residents to alert staff which poses a potential health and safety risk to 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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2023


LIC809 (FAS) - (06/04)
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