198204376-12-22-2021-28-AS-BTAO-C9Y28C-20211222161007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204376
Report Date: 12/22/2021
Date Signed: 12/22/2021 04:10:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	MOUNTAIN VIEW COTTAGES - IV		FACILITY NUMBER:	198204376
ADMINISTRATOR:	TRUPTI MODY		FACILITY TYPE:	740
ADDRESS:	21027 COVINA BLVD.		TELEPHONE:	(626) 966-4842
CITY:	COVINA	STATE: CA	ZIP CODE:	91724
CAPACITY:	6	CENSUS: 3	DATE:	12/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Jasbindar K Singh, Administrator		TIME COMPLETED:	04:30 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 Analysts (LPAs) Tao and Hanna conducted an unannounced annual inspection visit. LPAs met Jasbindar Singh, Administrator and explained the purpose of the visit. The facility has a capacity of six (6) to serve residents from age 60 and above which may have six (6) non-ambulatory and approved for four (4) hospice waiver. Current resident census is three (2). Two (2) residents are on hospice. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. This home is a single story house located in a residential neighborhood in Covina. It is a single story house with a ramp and a guard rail that leads to the front entrance, The facility consisted of five (5) bedrooms, two (2) bathrooms, office, living room, dining, room, kitchen, back yard and a carport The kitchen was clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. Each resident's bedroom had a dresser, chair and closet space available. Adequate linen and personal hygiene supply were observed. Bathrooms inspected and were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 113.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. (-continued in LIC 809 C-)

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOUNTAIN VIEW COTTAGES - IV	FACILITY NUMBER: 198204376
	VISIT DATE: 12/22/2021

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

Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers were fully charged and last service was on 1/20/21. Auditory devices were operable. Fire drill was conducted on 9/30/21. Administrator certificate had an expiration date on 4/11/23. The first aid kit was fully stocked. Mandated documents and signages were posted in common areas. The outdoor activity area had a shaded patio with ample seating. Medication is centrally stored. Resident records were stored in a locked storage room and inaccessible to residents. There are no pools and bodies of water on the premises. There were no firearms on the premises. Facility maintained a comfortable temperature of 73 degrees Fahrenheit for residents.

Deficiencies cited per California Code of Regulations, Title 22.

An exit interview was conducted. This report is discussed and provided to facility Administrator assistant, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOUNTAIN VIEW COTTAGES - IV	FACILITY NUMBER: 198204376
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303(a) Maintenance and Operation.(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, two stove burners on the left side of the stove are not working. Stove top had a chipped hole on the left side. This poses a potential health and safety risk to residents.
	POC Due Date: 01/04/2022
	Plan of Correction
1 2 3 4	Administrator stated the old stove will be replaced with a new stove by the due POC date.

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: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3