<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 12/04/2023
Date Signed: 12/04/2023 12:16:06 PM

Document Has Been Signed on 12/04/2023 12:16 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 CENTERFACILITY NUMBER:
197801605
ADMINISTRATOR:LAURA HERNANDEZFACILITY TYPE:
740
ADDRESS:715 WEST BASELINE ROADTELEPHONE:
(909) 626-6633
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 40CENSUS: 39DATE:
12/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Laura Hernandez- AdministratorTIME COMPLETED:
12:30 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) V. Maldonado made an unannounced visit at the facility for the purpose of citing deficiencies. LPA Maldonado met with Administrator, Laura Hernandez, and explained the purpose for the visit.

During a complaint visit initiated on 12/04/23, LPA Maldonado conducted a tour of the physical plant with Staff, Daisy Fitter, and conducted a file review for Residents# 1-3 (R1-R3). During the inspection of the facility kitchen, LPA observed an insufficient amount of the required 2-day perishables, for the amount of residents currently in care- 39 residents. LPA observed (1) box of frozen hamburger patties, about (3) boxes of frozen breakfast waffles, (1) gallon of milk, (2) packages of frozen chicken, (2) frozen full size hams, (1) package of frozen ground beef, about (9) tubs of yogurt, about (11) bags of frozen sliced sandwich bread, about (50) fresh eggs, one tub of varied fresh vegetables were observed in the refrigerator, and one and a half bags of assorted vegetables in the freezer. No fresh fruits were observed. Per Laura, the facility should be receiving a food delivery later today or tomorrow.

During the resident file review, LPA discovered that R2's file was missing an updated medical assessment (Physician's Report) as required annually for residents with dementia. The current Physician's Report is dated 11/18/22.

Per California Code of Regulations, Title 22, deficiencies were observed and cited on the LIC809-D.

An exit interview was conducted with Administrator, Laura Hernandez, and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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 12/04/2023 12:16 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 12/04/2023 at 11:29 AM
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: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2023
Section Cited
CCR
87555(b)(26)

1
2
3
4
5
6
7
87555 General Food Service Requirements
(b) The following food service requirements shall apply:(26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit pictures of receipts and purchased foods to LPA, via email, by POC due date.
8
9
10
11
12
13
14
Based on LPA's observation, there was an insufficient amount of the required 2-day persihable foods for the amount of residents in care, which poses an immediate Health, Safety, or Personal Rights risks to persons in care.
8
9
10
11
12
13
14
Type B
12/15/2023
Section Cited
CCR87705(c)(5)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment... which shall include a reassessment of the resident’s dementia care needs.
This rquirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee provided LPA a copy of updated Physician's Report dated 12/03/23. POC cleared.
8
9
10
11
12
13
14
Based on LPA's observation and interview, the licensee failed to obtain an annual medical assessment/Physician's Report for R2 as required, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023


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