<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204372
Report Date: 09/28/2023
Date Signed: 09/28/2023 05:08:24 PM


Document Has Been Signed on 09/28/2023 05:08 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 -IIFACILITY NUMBER:
198204372
ADMINISTRATOR:TRUPTI MODYFACILITY TYPE:
740
ADDRESS:1000 PARK SPRING LANETELEPHONE:
(909) 860-6558
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:4CENSUS: 4DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Trupti ModyTIME COMPLETED:
05:00 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) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 09/28/2023 at 10:27 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Facility is licensed to serve four (4) residents ages 60 and above, of which three (3) may be non-ambulatory and one (1) bedridden. The facility provides dementia care for residents and serves developmentally disabled residents. All residents receive services from San Gabriel Valley/Pomona Regional Center.

LPA OBSERVATIONS: Tour began at 10:32 am and was led by S1. The facility is a single-story building located in a residential neighborhood with three (3) resident bedrooms, four (4) staff bedrooms, three (3) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed. Front door screen is torn/ripped near the handle.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to three (3) out of three (3) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to three (3) out of three (3) residents in care. Kitchen sink water temperature was measured at 112.8 degrees F. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed several missing curtain blinds from living room window. LPA Ramirez will issue Type B deficiency. LPA Ramirez observed fully charged fire extinguisher in this area. LPA Ramirez observed one (1) out of three (3) residents, attending day program via zoom, in living room during visit.

Linen Closet: Contained plenty linens, towels, hygiene products, and extra PPE supplies. Linen closet was observed to be inaccessible to three (3) out of three (3) residents in care.



SEE LIC 809-C.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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 5


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 -II
FACILITY NUMBER: 198204372
VISIT DATE: 09/28/2023
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
26
27
28
29
30
31
32
Resident Rooms 1 - 3: LPA Ramirez observed all three (3) resident bedrooms to contain required furnishings, lighting, and linens. Resident bedroom #1 is a shared bedroom however, only one (1) resident is currently occupying this room. LPA Ramirez observed required auditory devices to sound when resident patio door is opened. Resident bedroom #2 windows covering were observed to be dusty. LPA Ramirez with issue Type B deficiency.

Bathrooms: Signs promoting hand washing were observed in all bathrooms. Water temperature in private resident bathroom#1, located in resident bedroom#1, was measured at 116.6 degrees F which is in the required 105 – 120 degrees F. Shared bathroom #2 was observed to be clean and water temperature was measured at 114.8 degrees F which is in the required 105 – 120 degrees F. Shared bathroom #3 was observed to be clean and water temperature was measured at 113.0 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and in walk-in showers, in all bathrooms.

Centrally Stored Medications: LPA observed cabinet located in kitchen area to contain centrally stored medications. This cabinet was observed to be inaccessible to three (3) out of three (3) residents in care.

Backyard: LPA observed a large tree branch in backyard area and was blocking a passageway to the side of the facility. According to S1, the winds knocked down the large branch on 9/28/23 during breakfast. LPA Ramirez will issue Technical Advisory.

Emergency Drills: Facility could not provide emergency drills were conducted and documented since 1/12/23. LPA Ramirez will issue Type B deficiency.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Staff Personnel Files: Staff files are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. LPA Ramirez observed Administrator’s certificate for Trupti Mody with an expiration date of 05/31/2022. Per Administrator Mody, Administrator’s certificate is pending renewal.

Resident Files: Three (3) resident files were reviewed. Resident#1 (R1) record did not have complete and signed medical assessment. LPA Ramirez will issue Type B deficiency.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.



Deficiencies are being cited. Exit interview was conducted with Administrator Mody and a copy of this report, LIC 809-D, LIC 9102 and appeals rights was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/28/2023 05:08 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MOUNTAIN VIEW COTTAGES -II
FACILITY NUMBER: 198204372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, missing blinds in the livingroom area dust in resident bedroom#2 blinds and front screen door is torn, the licensee did not comply with the section cited above in 3 out of 3 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2023
Plan of Correction
1
2
3
4
Licensee will replace missing blinds in livingroom area, clean blinds in resident bedroom #2 and repair torn screen on front door. Licensee will submit pictures of corrections to LPA via email.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, Resident#1 was missing completed and signed medical assessment, the licensee did not comply with the section cited above in 1 out of 3 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2023
Plan of Correction
1
2
3
4
Licensee will submit completed and signed medical assessment of R1 to LPA via email.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/28/2023 05:08 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MOUNTAIN VIEW COTTAGES -II
FACILITY NUMBER: 198204372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, emergency drill was not conducted quarterly or documented, the licensee did not comply with the section cited above in 3 out of 3 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2023
Plan of Correction
1
2
3
4
Licensee will conduct quarterly drills and document the drill. Proof of recent drill must be emailed to LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5