198204371-4-12-2023-28-AS-CDCN-CQTPDH-20230412111333

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204371
Report Date: 04/10/2023
Date Signed: 04/12/2023 11:13:42 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/12/2023 11:13 AM - 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 - V		FACILITY NUMBER:	198204371
ADMINISTRATOR:	TRUPTI MODY		FACILITY TYPE:	740
ADDRESS:	1738 MAPLE HILL ROAD		TELEPHONE:	(909) 860-7534
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	4	CENSUS: 4	DATE:	04/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Eva Nainggolan, DSP		TIME COMPLETED:	01:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Staff, Eva Nainggolan, who allowed entry. The purpose for the visit was explained. The facility is licensed to serve 4 non-ambulatory residents ages 60 and over, of which 1 may be bedridden. The bedridden resident is approved for bedroom #5. The facility serves developmentally disabled residents who are placed by the San Gabriel/Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are cleaning and disinfecting at least every 2 hours. Facility has sufficient PPE supplies and submitted an Infection Control Plan. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 3 non-ambulatory and 1 ambulatory residents residing at the facility. Physical Plant & Environment Safety: The facility has no swimming pool or bodies of water on the premises. The fireplace is not in used and is fenced. There are 4 resident bedrooms, 1 live-in staff room, 1 vacant room, 3 bathrooms, living room, dining room, kitchen, and an attached garage. Facility has an operable smoke detector in each room and 2 carbon monoxide detectors at the home. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to residents. There are no firearms or weapons stored at the facility. The hot water temperature was measured between the required range of 105-120 degrees F. Staffing: There is sufficient staffing at the facility. Staff employed have fingerprint clearance and associated to the facility.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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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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 COTTAGES - V	FACILITY NUMBER: 198204371
	VISIT DATE: 04/10/2023

NARRATIVE

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Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement.
Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Regional Center's IPP reports, and Resident rights.
Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability.
Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator.
Incidental Medical & Dental: The medications are centrally stored and in their original bubble packs. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed all 4 residents' medications and they are being administered as prescribed by the physician.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia.

LPA interviewed 2 Staff and a resident during the visit. No deficiencies were issued today. Technical advisories were provided. An exit interview was held. A copy of this report, technical advisory notes, and appeal rights were given to Staff Anwar.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC809 (FAS) - (06/04)

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