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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801605
Report Date: 10/06/2022
Date Signed: 10/06/2022 05:40:06 PM

Document Has Been Signed on 10/06/2022 05:40 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: 31DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Laura HernandezTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs): Elizabeth Irra and Noemi Galarza and conducted an annual comprehensive inspection visit. LPA Irra met with Laura Hernandez and explained the purpose of today's visit. During this visit, Accusation CDSS No.6221326301D was observed posted as required by Law. It was posted and readily accessible.

A tour of the facility was conducted. 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, residents rooms, living room, dinning room, bathrooms, and indoor/outdoor areas.

Residents bedrooms have the required furniture. Bathrooms are clean and operational.

The following bathrooms hot water temperature was not within the required range of 105-120 degrees F; Restroom in Wing #2 water temperature measured at 123*. Restroom between room #2 and room #3 water temperature measured at 124.5*. Restroom between room #6 and room #7 water temperature measured at 122.3*. Restroom between room #8 and room #9 water temperature measured at 124*. Restroom between room #18 and room #19 water temperature measured at 103.2*. Restroom between room #14 and room #15 water measured at 100.4*.

LPA's observed an appropriate food supply of two (2) days of perishables and seven (7) days of non-perishables. There is an additional storage area of food supply for emergency preparedness. All storage areas for chemical compounds, cleaning solutions, toxins, knives or hazardous items are located in the front building.



Refer to LIC 809C for the continuation of this report.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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Document Has Been Signed on 10/06/2022 05:40 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 10/06/2022 at 01:41 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: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(16)
87555 General Food Service Requirements (b) The following food service requirements shall apply: (16) In facilities licensed for sixteen (16) to forty-nine (49) residents, one person shall be designated who has primary responsibility for food planning, preparation and service. This person shall be provided with appropriate training.

This requirement is not met as evidence by: S-5’s Food Handling Training Certificate expired 11/24/2021.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in S-5/Cook did not have a current Food Handling Training Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Facility Administrator to submit proof of Food Handling Training enrollment for S-5 and submit to LPA Irra by POC due date of 10/13/22.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by: S-4- First Aid/CPR Certificate issued 09/28/2020 (2 year certification). Expired: 09/28/2022.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as S-4 First Aid/CPR Certificate expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Facility Administrator to submit proof of enrollment for first aid certification for S-4 to LPA Irra by POC due date of 10/13/2022.
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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


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Document Has Been Signed on 10/06/2022 05:40 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 10/06/2022 at 04:20 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: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(i)(1)(B)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section above in that the signal system is non-operational throughout the facility. Per Administrator, the signal system has been out of service for approximately (2) months. Per Administrator, Residents that are able to request for assistance were given a hand held bell to use; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2022
Plan of Correction
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Administrator shall submit a written plan stating how the facility will address the deficiency and repair plans.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


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Document Has Been Signed on 10/06/2022 05:40 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 10/06/2022 at 04:20 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: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that R-1 (room#8), R-5 (room #6), R-9 has oxygen concentrators inside their bedroom but did not have oxygen in use signage; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Administrator shall place an oxygen sign on the resident's doors. Submit picture proof by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


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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: 10/06/2022
NARRATIVE
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Carbon monoxide device(s) were tested and were found to be operational. Fire extinguishers are fully charged and were last serviced on 01/19/2022. The facility signal systems are not operational throughout the facility. Per Administrator, the signal system has been out of service for approximately (2) months. Per Administrator, Residents that are able to request for assistance were given a hand held bell to use.

Passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris. There are no security bars nor weapons or bodies of water (pool/spa) on the premises.



LPAs reviewed Staff files for Staff #1 though Staff #5 (S-1 through S-5). LPAs also reviewed Resident files for Resident #1 through Resident #10 (R-1 through R-10).

LPA observed the CCL "Let us no" complaint poster posted. However, the poster measured 8" x10" as opposed to the required measurement of 20" x 26" as per Title 22.

The following deficiencies were observed to be in violation under California Code of Regulation Title 22. Refer to LIC 809D.

Exit interview, Appeal Rights and a copy of this report was provided to Laura Hernandez.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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Document Has Been Signed on 10/06/2022 05:40 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 10/06/2022 at 05:07 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: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio, the licensee failed to comply with the section above in that restroom in Wing #2 water temperature measured at 123*. Restroom between room #2 and room #3 water temperature measured at 124.5*. Restroom between room #6 and room #7 water temperature measured at 122.3*. Restroom between room #8 and room #9 water temperature measured at 124*. Restroom between room #18 and room #19 water temperature measured at 103.2*. Restroom between room #14 and room #15 water measured at 100.4*; which poses an immediate health and safety risk to persons in care.

POC Due Date: 10/07/2022
Plan of Correction
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Administrator shall adjust water temperature and submit a water temperature log by the end of business day tomorrow. Include a written statement that states the facility's protocols in ensuring the hot water temperatures will be maintained according to Title 22 regulations.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2022 05:40 PM - It Cannot Be Edited


Created By: Elizabeth Irra On 10/06/2022 at 05:11 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: 10/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights
Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public...(A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee failed to comply in the section above in that LPA observed the CCL "Let us no" complaint poster posted. However, the poster measured 8" x10" as opposed to the required measurement of 20" x 26" as per Title 22; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Administrator shall submit proof that a 20 x 26 complaint poster has been posted.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Elizabeth Irra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022


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