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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204371
Report Date: 02/19/2021
Date Signed: 02/19/2021 03:45:43 PM

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 COTTAGES - VFACILITY NUMBER:
198204371
ADMINISTRATOR:TRUPTI MODYFACILITY TYPE:
740
ADDRESS:1738 MAPLE HILL ROADTELEPHONE:
(909) 860-7534
CITY:DIAMONDSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 0DATE:
02/19/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Trupti ModyTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) met with administrator Trupti Mody for a COVID-19 Case Management visit and explained the purpose of today's visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, today's case management was conducted telephonically with the facility administrator. The administrator stated that the residents have been relocated since 12/10/21 but anticipates Regional Center's approval for their return by next week. There were no residents or staff present at the facility.

LPA Spencer began with a tour of the facility and inspected the signage, universal screening area, dining rooms, living rooms, resident rooms, thermometers, trash cans, paper supply, water supply, food supply, PPE supply, laundry rooms, backyard and cleaning supply storage area. Signage for donning and doffing, hand-washing, visitation policy and COVID-19 symptoms were observed. There were sign in sheets, temperature logs, and symptoms screening logs. In the restrooms, LPA Spencer observed soap, paper towels, toilet paper and covered trash cans. Each resident had their own separate covered laundry container. PPE storage included 30+ days worth of: gloves, gowns, hand sanitizer, face shields, disinfectant wipes, and surgical masks. For the water supply, there were 4 (3) gallon waters. The disinfectant used is bleach and water solution and administrator stated that it is changed daily. There were hand-washing posters in the bathroom. The living room couch had middle cushions removed to allow 6 feet of space. The dining room chairs were spaced 6 feet apart. The backyard patio furniture was spaced at least 6 feet apart to encourage social distancing. There were PPE supplies near the screening area, laundry area, and garage. The administrator discussed her mitigation plan, staff training, symptom check procedures, and staffing plan. All plans were in compliance with CCL guidelines.

There were no deficiencies cited at this time. An exit interview and a copy of this report was provided to the administrator who was asked to sign and return to LPA by 2/19/21.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
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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