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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204371
Report Date: 03/05/2024
Date Signed: 03/05/2024 03:17:59 PM


Document Has Been Signed on 03/05/2024 03:17 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:4CENSUS: 4DATE:
03/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Eva Nainggolan, DSPTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection on 3/5/24. LPA arrived unannounced and met with Staff, Eva Nainggolan. The purpose for the visit was explained. Administrator, Trupti Mody, arrived shortly after to assist with the visit. The facility is licensed to serve 4 non-ambulatory residents ages 60 and over, of which 1 may be bedridden. Bedroom #5 is approved for the bedridden resident. The facility serves developmentally disabled residents who are placed by the San Gabriel/Pomona Regional Center. There are currently 3 non-ambulatory and 1 ambulatory residents residing at the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools and observed the following:
The single story facility consists of 4 resident bedrooms, 2 staff rooms, 2.5 bathrooms, living room, dining room, kitchen, and attached garage. The fireplace is secured by a fence. There are no swimming pool or bodies of water on the premises. Facility has interconnected 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. The hot water temperature was measured between the required range of 105-120 degrees F. The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. The facility has a dementia care plan to accept or retain residents with dementia. LPA reviewed 4 personnel files. Staff employed have fingerprint clearance and associated to the facility. They have the required documents and training hours in their files. Staff have current CPR & First aid certificates. Resident files are also maintained at the facility and have the following documents in their files such as Admission Agreements, Identification & Emergency Information, Physician's Report, Regional Center's IPP reports, and Resident rights. The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical/mental capability.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 03/05/2024
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There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator. Medications are centrally stored in the kitchen cabinet. LPA reviewed 4 resident medications and they are being administered as prescribed.
The facility has the Emergency Disaster Plan with contact numbers, at least 2 relocation sites, and procedures in case of emergency.

There are no deficiencies issued today. An exit interview was held and a copy of this report was given to administrator Trupti.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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