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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204372
Report Date: 12/12/2023
Date Signed: 12/12/2023 12:05:35 PM

Document Has Been Signed on 12/12/2023 12:05 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: 2DATE:
12/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Cherry Serame, StaffTIME COMPLETED:
12:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit in response to an incident report sent to licensing on 11/20/23. LPA arrived unannounced and met with Staff, Cherry Serame. The purpose of the visit was explained.

The incident report indicated that Resident #1 (R1) developed a wound on 11/20/23 that was unstageable at the time. During the visit today, LPA reviewed medical notes and interviewed staff. Staff interviewed stated that they first noticed redness on the right buttock of R1 on 11/10/23. They immediately informed the administrator who contacted the home health agency. On 11/13/23, a home health nurse conducted the initial visit to evaluate and treat the wound. Based on the Omni Home Health progress notes dated 11/24/23, the wound on the right hip was evaluated as a stage 3. The nurse had recommended to turn R1 every 2 hours and to keep the skin clean and dry. Additional progress notes dated 12/1/23 and 12/5/23 indicated the pressure ulcer was at stage 4. R1 was transferred to a Skilled Nursing Facility as initiated by the Regional Center personnel on 12/6/23. Staff interviewed stated R1 was not on hospice and the wound appeared to be healing while in care. They also stated R1 was turned every 2 hours. However, at night, a staff would check on R1 once, between 8pm - 6am, and turn R1 at that time.

Based on the information gathered, the facility retained resident with a stage 3 or 4 wound which is considered a prohibited health condition. Therefore, a deficiency is being cited on the LIC809D. An exit interview was held and a copy of this report along with appeal rights were given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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Document Has Been Signed on 12/12/2023 12:05 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 12/12/2023 at 11:17 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/13/2023
Section Cited
CCR
87615(a)(1)

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87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
This requirement is not met as evidenced by:
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The licensee shall review the prohibited health conditions regulation and shall not retain a resident with staff 3 and 4 pressure injuries. Resident #1 shall be transferred out of the facility by POC due date 12/13/23.
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Based on interview and records review, the facility retained
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**This deficiency has been cleared today as R1 had been relocated to a SNF.

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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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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