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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 07/12/2022
Date Signed: 07/12/2022 02:50:35 PM

Document Has Been Signed on 07/12/2022 02:50 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: 24DATE:
07/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Laura HernandezTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Case Management visit to check the health and safety of residents, and to ensure Accusation/CDSS No. 6221326301D was posted as required by Law. LPA explained the purpose of the visit to Laura Hernandez.
  • There are (5) residents currently receiving hospice care services.
  • Accusation/CDSS No.6221326301D was observed posted as required by Law. It was posted and readily accessible.
  • LPA conducted a tour of the premises and no health and safety concerns were observed.
  • LPA informed Laura Hernandez that all new residents being admitted into this facility be informed of the accusation noted above.

During this visit, LPA also reviewed and collected documentation pertaining to a request for locked perimeters of this facility.

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

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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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