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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204371
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:19:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230105100553
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:
01/12/2023
UNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:DSP Siaful Anwar, Administrator Trupti ModyTIME COMPLETED:
01:31 PM
ALLEGATION(S):
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Facility staff are not wearing masks.
INVESTIGATION FINDINGS:
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LPA made initial 10 day visit to investigate the above allegation. LPA was greeted by DSP Siaful Anwar and Administrator showed up about 1 hour later.

Regarding the Allegation: Facility staff are not wearing masks. When LPA arrived at facility and was greeted by S1, S1 was wearing a mask. LPA interviewed 3 staff (S1-S3) and 2 residents (R1-R2) R3 and R4 were not able to answer questions. 3/3/ staff stated they always wear mask on duty. 2/2 residents interviewed stated staff are always wearing mask. LPA observed all three staff wearing mask during entire visit.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted, a copy of this report and Appeal Rights were provided to Administrator

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/05/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230105100553

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:
01/12/2023
UNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:DSP Siaful Anwar, Administrator Truupti ModyTIME COMPLETED:
01:31 PM
ALLEGATION(S):
1
2
3
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5
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9
Facility has pests.
Facility does not have phone service.
INVESTIGATION FINDINGS:
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LPA Lopez made initail 10 day visit to investigate the above allegations. LPA was by DSP Siaful Anwar and Administrator showed up about 1 hour later.

Regarding Allegation: Facility has pests. The investigation revealed that facility has investation of roaches as LPA and S1 observed lving and dead roaches in the kitchen cabinets. 3/3 staff admitted to the infestation of roaches and have been addressing it by using Combat gel. 1//2 residents inteeviewed stated they have observed roaches in the facility.

Based on LPAs observations and interviews which were conducted and recorded, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

(Continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20230105100553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/12/2023
NARRATIVE
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Regarding Allegation: Facility does not have phone service. LPA attempted to call facility on 01/10/2023 and phone was not working. 3/3 staff interviewed stated that phone was out of order until 01/11//2023. S2 stated that phone was not working for a while. S3 acknowledged that phone was not working and stated reason was not known. 1/2 residents stated facility has working phone now. 1/2 resident reported that phone was not working for about 1 week. LPA called the facility phone during the visit and it was functioning properly.

Based on LPAs observations and interviews which were conducted and recorded, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated.

Deficiencies cited, Please see 9099D for details
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20230105100553
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/26/2023
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met by evidence of:
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Administrator will contact the licensee and ask for treatment of the roach infestation. Administrator will send copy of invoice or proof that professional pest control has rendered services and send proof to LPA by POC dated.
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LPA and S1 observed living and dead roaches in the kitchen cabinets and surrounding area.
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Type B
01/13/2023
Section Cited
CCR
87311
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All facilities shall have telephone services on the premises.

This requirement is not met by evidence of:
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Administrator will make sure facility has working phone services at all times, ,
****Phone service at facility was working properly during visit and no further action is required.****
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LPA attempted to call on 01/10/2023 and phone was not working. 2 staff and administrator stated phone was not working for some time.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4