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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204371
Report Date: 03/25/2022
Date Signed: 03/25/2022 01:34:48 PM


Document Has Been Signed on 03/25/2022 01:34 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 COTTAGES - VFACILITY NUMBER:
198204371
ADMINISTRATOR:TRUPTI MODYFACILITY TYPE:
740
ADDRESS:1738 MAPLE HILL ROADTELEPHONE:
(909) 860-7534
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:6CENSUS: 4DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Staff, Eva NainggolanTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Staff, Eva Nainggolan who assisted with visit and spoke with Administrator, Trupti Mody, via phone call during the visit. Facility serves. Facility is licensed to serve six (6) non-ambulatory, developmentally disabled residents who are age 60 and above. Annual licensing fees is current. Administrator certificate is current and the expiration date is 05/31/2022. All current residents were placed by San Gabriel/Pomona Regional Center (DD - Level IV (C) clients.


During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed.

The facility is located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility has five (5) resident bedrooms and one (1) staff bedroom, two (2) full bathrooms, one (1) half bathroom, living area, kitchen, dining room, and an indoor/covered outdoor activity area. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 113.6 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely.

Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers’ last service is 01/26/22 and are fully charged. ( - Continued in LIC 809 C-)
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - V
FACILITY NUMBER: 198204371
VISIT DATE: 03/25/2022
NARRATIVE
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The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates.

Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D.

An exit interview was conducted. This report was discussed with Administrator, Trupti and Staff, Eva. Staff’s signature on this form confirm receipt of these documents. A copy of LIC 809s report and appeal rights were provided.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/25/2022 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - V
FACILITY NUMBER: 198204371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(6)
Personal Rights of Residents in All Facilities
To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation during physical plant inspection, LPA observed an exit side gate on left side of the facility was a turn knob but was locked with a key lock. It required a key to unlock. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2022
Plan of Correction
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Key lock on the exit side gate was removed during the visit. Licensee to ensure that all exit gates shall remain unlocked at all times. Administrator agrees to submit a self-certification to ensure that all exit gates shall remain unlocked at all times to Licensing 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/25/2022 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 - V
FACILITY NUMBER: 198204371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:

Old furniture and trash were piled up at the backyard.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/30/2022
Plan of Correction
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Licensee agrees to remove old furniture and trash from the backyard. Licensee will submit a picture of the cleared backyard 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: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4