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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204371
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:33:51 PM


Document Has Been Signed on 03/13/2023 03:33 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 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:
03/13/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Trupti Mody, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit for a capacity change. LPA met with Administrator Trupti Mody. The licensee initiated a capacity change from 6 to 4. The fire clearance was approved on 10/26/22 for a total of 4 developmentally disabled residents, ages 60 and above: (3) non-ambulatory and (1) bedridden. Only (1) bedridden resident is approved for room #5. Rooms #2, #3, #4, and #5 are designated as resident rooms. All 4 residents were placed by the San Gabriel/Pomona Regional Center.

LPA toured the facility and observed the following:
* Rooms #2, #3, #4, and #5 are occupied by residents. Each resident currently has their own room and has the required furniture.
* Room #1 is being used as storage and will be used as a staff room.
* The room next to the kitchen is used by the live-in staff.
* There are extra clean linens and towels for residents.
* There are tables and chairs set up for 4 residents.
* The food supplies are sufficient for the current census.

An exit interview was conducted. A copy of this report was given to Administrator Mody.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023
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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